Every finding on record at Health Care Auth for Baptist Health, Af of Uab Health System

Observed in Record Review. In 1 of 16 patient records reviewed, the organization failed to assess and reassess its patient's. During record review for RRHV#2, the Hospice Nurse Surveyor observed the wound documentation did not include staging for the sacral pressure ulcer as required by organizational policy. This was discussed and reviewed with the Hospice Team.

Observed in Record Review. In 6 of 16 patient records reviewed, the organization failed to plan the patient's care. During record review for RRHV#1, RRHV#2, RRNHV#1, RRNHV#3, RRNHV#5, RRNHV#10 ..... the Hospice Nurse Surveyor observed the plan of care did not contain all needed elements. For example in RRHV#1, the patient had a goal of the patient will receive socialization during visits with her SW at capitol hill to help promote mental and social stimulation. This goal was not measurable. In RRHV#2 had a goal of verbalizes meaningful relationship to chaplain by providing spiritual support through scripture reading and prayer. This goal was not measurable. In RRNHV#1 the patient had a goal of PT/ CG will cope with the end of life issues and dying process as evidence by expressing their feelings and emotions appropriately during SW visits which was not measurable and the target date was set for 4 months in the future. In RRNHV#3, the patient had a goal of Pt/ CG will verbalize feelings of adequate emotional support during visits and or phone calls and chaplain to provide pastoral relationships as evidenced by playing spiritual songs and prayer. These goals were not measurable. In RRNHV#5 the patient had a goal of verbalize and demonstrate proper wound care. The wound care had been discontinued and the wound healed 14 days prior to survey but the goal was not resolved. In RRNHV#1- the patient had a goal of expressing thoughts and emotions appropriately to SW visits which had no measurable outcomes. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Record Review. In 1 of 16 patient records reviewed, the organization failed to plan the patient's care. During record review for RRNHV#10, the Hospice Nurse Surveyor observed the plan of care did not contain all needed elements. During record review for RRNHV#10, the patient primary diagnosis was abnormal weight loss. The patient was on hospice for approximately a month, and had lost 80 pounds in the last 6 months. There was nothing to address nutrition and weight loss on the plan of care. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Tracer Activities. The organization did not have a process to inform patients/caregivers about rights related to payment. In review of the documents provided to patients, there was no place in which to indicate that there was no payment required from patients with Medicare. This was confirmed with the Director.

Observed in Record Review. In 3 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 the chart for HV#3, the Chaplain goals on the current plan of care had been anticipated to be met prior to the end of the previous benefit period. Additionally, the MSW goal was actually an intervention, Provide patient/CG with viable resources... not a goal as confirmed with the Director. In the charts for RR#6 and RR#8, goals had not been individualized in that all goals had the anticipated achievement date as the last day of the benefit period. Additionally, in the chart for RR#6 the MSW goal was an intervention.

Observed in Record Review. In 4 of 13 patient records reviewed, the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions including medications and treatments necessary to meet the patient's needs. In the charts for HV#1, HV#2 and HV#3, the oxygen orders were incomplete and stated the oxygen was to be used as directed. Per discussion with the Hospice Director and RN's at the visits, the actual order was oxygen prn. In the chart for HV#3, the patient was assessed to be at risk for falls and pressure ulcer development, however the plan of care did not include any interventions nor goals related to these risks. In the chart for HV#2, the POC included for the SN to administer enema as ordered; however no enema was ordered; perform digital stimulation as indicated - no indication nor frequency was included; remove fecal impaction manually - no frequency or indication. In the chart for RR#1, the Plan of Care did not include any orders for the central line flushes that the RN documented were being provided by the patient's mother/PCG. These findings were confirmed with the Director.

Observed in Document Review. In 1 of 4 contracts reviewed, the written agreement did not contain required elements. In the contract for DME, there was no stipulation that services be delivered in accordance with the POC as confirmed with the Director.

Observed in Record Review. In 1 of 13 patient records reviewed, when the patient was transferred, the organization had not informed other service providers. In the chart for RR#9, the patient was transferred to the hospital, however no information from the patient's clinical record was offered nor sent to the receiving facility as confirmed with the Director.

Observed in Record Review. In 3 of 13 patient records reviewed, the organization had not provided the patient/PCG with written policies and procedures for managing controlled medications at admission when there were ordered. In the charts for RR#2, RR#7 and RR#8 this education was not documented as confirmed with the Director.

Observed in HR File Review. In 1 of 8 HR files reviewed, the organization had not verified licensure at time of renewal. In the file for the MSW, the most recent verification of renewal of licensure occurred 3 days post expiration as confirmed with the Director.