Every finding on record at Health First Hospice, Inc

Observed in Record Review. In 11 of 11 patient records reviewed, the hospice failed to conduct a comprehensive reassessment in accordance with the organization's Ongoing Comprehensive Assessment policy. All required elements identified in the policy were not addressed in the documentation. This was reviewed with Administrator and QAPI LVN.

Observed in Record Review. The hospice registered nurse did not complete the initial assessment within 48 hours of the election of hospice care. In the record of RR#4 it was found that the Medical Director documented completion of an admission assessment. This was reviewed with the Administrator and QAPI LVN.

Observed in Record Review. The hospice registered nurse did not visit the patient within five calendar days of the election of hospice care to complete the comprehensive assessment in the record of RR#4. This was reviewed with the Administrator and QAPI LVN.

Observed in Record Review. The organization did not assess potential medication related problems including duplicate therapy. In a majority of records reviewed therapeutic duplication for the treatment of constipation was noted, but there was no documentation that it was addressed by the interdisciplinary team. This was reviewed with the Administrator and QAPI LVN.

Observed in Record Review. In 3 of 11 patient records reviewed, the organization failed to complete bereavement assessments as part of the initial comprehensive assessment in the record of RR#1. In the records of RR#7 and RR#8 risk assessments were incomplete. And RR#8 did not include a post death bereavement assessment. This was reviewed with the Administrator and QAPI LVN.

Observed in Record Review. In 1 of 11 patient records reviewed, The interdisciplinary group did not update the comprehensive assessment every 15 days or less. This could not be done because the elements required of a comprehensive assessment were not gathered by an RN prior to the meeting. This was reviewed with Administrator and QAPI LVN. Observed in Record Review. In 3 of 11 patient records reviewed, the surveyor found that not all core members of the interdisciplinary team attended meetings in person. In the records of RR#3, RR#4 an RR#5 an RN did not document attendance by electronic signature. Nor was there any indication that collaboration occurred outside of the meeting. This was reviewed with the Administrator and QAPI LVN.

Observed in Record Review. the organization did not plan patients’ care, treatment, or services based on needs identified by the assessment. In the record of RR#4 the plan of care was not created until 14 days after admission. This was reviewed with the Administrator and QAPI LVN.

Observed in Record Review. In 11 of 11 patient records reviewed, the organization did not ensure that goals established in the patient’s plan of care evaluated progress. In every record reviewed it was noted that most goals were generic, did not include measurements to indicate progress or decline, and had identified completion dates for the following week. And in one record, goals created when a patient was admitted 18 months prior to this survey date were not revised or marked as completed. This was reviewed with Administrator and QAPI LVN.

Observed in Record Review. In the record of HV#3 it was documentation that a CHHA was visiting twice weekly, however there was no order for this in the plan of care. This was reviewed with the Administrator and QAPI LVN.

Observed in Record Review. During HV#1 the surveyor observed that the patient was using oxygen at 3 liters per minute per nasal cannula via concentrator. A review of the record found no order for oxygen since admission 18 months prior to this survey. This was reviewed with Administrator and QAPI LVN.

Observed in Record Review. In the record of RR#3 an RN documented that she changed a foley catheter, however there was no order in the plan of care to do so. This was reviewed with the Administrator and QAPI LVN.

Observed in Record Review. the hospice did not provide the patient with care, treatment, or services according to the patient’s plan of care. In every record the MSW documented that the visits were conducted telephonically. And in the record of RR#5 an LVN also documented that the visits were conducted telephonically. This was reviewed with the Administrator and QAPI LVN. Observed in Record Review. In 1 of 11 patient records reviewed, the hospice did not provide the patient with care, treatment, or services according to the patient’s plan of care. In the record of RR#4 it was found that an RN did not visit the patient every 14 days as specified in the plan of care. This was reviewed with the Administrator and QAPI LVN.

Observed in Data Session. During the leadership session, the surveyor learned that the organization did not use the data collected to monitor the effectiveness and safety of services and the quality of care. This was reviewed with the Administrator and QAPI LVN.

Observed in Data Session. During the leadership session, the surveyor learned that the organization’s governing body did not approve the frequency and detail of the data collection. This was reviewed with the Administrator and QAPI LVN.

Observed in Leadership Session. During the leadership session, the surveyor learned that the organization's leaders failed to establish organization-wide performance improvement. This was reviewed with the Administrator and QAPI LVN. Observed in Leadership Session. During the leader session, the surveyor learned that the organization's leaders did not give priority to high-volume, high-risk, or problem-prone processes for performance improvement activities and reprioritize performance improvement activities in response to changes in the internal or external environment. This was reviewed with the Administrator and QAPI LVN.

Observed in Patient Home. In 1 of 3 home visits conducted, staff did not clean equipment according to policy. During HV#1 a CHHA did not clean all surfaces of a used blood pressure cuff prior to returning to the clean section of the visit bag. This was reviewed with Administrator and QAPI LVN.

Observed in Tracer Activities. During survey it had been identified that the hospice had one or more individuals who perform leadership functions, but had not functioned with the authority, responsibility or accountability to direct the hospice and its key activities and operations. On day one it was learned that the DPCS is a Director of Nursing at a skilled nursing facility and is not available to provide daily clinical management and over site. The DPCS Designee was out of the country. This was reviewed with Administrator and QAPI LVN.

Observed in Record Review. In 2 of 2 patient records reviewed, where patients died, the hospice did not document that bereavement plans of care were developed. This was found in the records of RR#7 and RR#8 and was reviewed with the Administrator and QAPI LVN.

Observed in Record Review. The organization did not provide care according to the patient’s individualized plan of care. At HV#1 a CHHA stated that she did not shampoo the patient’s hair during every bed bath. The aide plan of care directed this be done at every visit. This was reviewed with Administrator and QAPI LVN.

Observed in Leadership Session. The Governing Body did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews: - §418.54 §418.64 §418.100 and §418.56.

Observed in Record Review. During HV #3 the surveyor noted that the medication profile in the home was inaccurate. MOM was listed as every 6 hours, but the label read daily. Ondansetron HCL 4 mg prn for nausea and vomiting was not on the medication list. Gabapentin 300 mg twice daily and Losartan 160 mg daily were both ordered 24 days prior to this home visit, however, neither were documented on the medication list. This was reviewed with the Administrator and QAPI LVN.

Observed in Leadership Session. The hospice did not have a process for discharging patients for cause, or for those wanting to revoke the hospice benefit. Leaders did not require patients to sign revocation forms when choosing to seek aggressive care. As well, a Notice of Medicare Non-Coverage was not provided 48 hours in advance for a patient discharged for cause. This was reviewed with the Administrator and QAPI LVN.