Every finding on record at Heart of Gold Hospice, Inc.

Observed in Tracer Activities. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by not ensuring the following Condition of Participation was met as determined through observation, documentation, and staff interviews: 418.100 - Organization and Administration of Services. This was reviewed and validated with the Administrator.

Observed in Record Review. In 2 of 11 patient records reviewed, the organization did not conduct the patient's initial assessment in accordance with written time frames and in accordance with organizational policy No. 2-030.1-Comprehensive Assessment - A comprehensive patient assessment will be performed by the hospice IDG no later than 5 calendar days after the election of hospice care . . .. For example, identified in the record review for HV#1, the initial comprehensive Spiritual Care assessment and the Initial Bereavement Risk Assessments were not completed until day six (6) following the start of care date. Identified in the record review for RR#7, the initial comprehensive Psychosocial assessment was not completed until day 7 following the start of care date. This was reviewed and validated with the Administrator and Director of Patient Care Services.

Observed in Tracer Activities. In 1 of 3 home visits conducted there was no evidence that the patient's skin had been thoroughly assessed. Observed in HV#3, during the Surveyor's home visit with the Licensed Vocational Nurse, the patient was assessed to have a large healing bruise on the left lateral lower extremity below the knee measuring approximately 4 inches wide by 8 inches long. The caregiver stated that the patient had the bruise upon admission to the Board & Care, which was the same date of the hospice admission. In review of the patients record, there was no documentation of this skin impairment following the 4 skilled nursing visits that had occurred since the start of care date approximately 3 weeks prior to the survey date. This was reviewed and validated with the Administrator and Director of Patient Care Services. Observed in Patient Home. In 1 of 3 home visits conducted, the hospice did not conduct a patient-specific comprehensive re-assessment in accordance with the organization's policy No. 2-031.1 - Ongoing Comprehensive Assessments - , The Nurse will assess the patient on each visit, for: G - Skin integrity. For example, observed in HV#1, the Registered Nurse assessed the patient who was lying in a hospital bed, but did not reposition or remove clothing to fully assess the patient's anterior and posterior skin or her feet. This was reviewed and validated with the Administrator and Director of Patient Care Services.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization did not conduct an initial bereavement assessment of the needs of the patient's family. Identified during the review of RR#7, there was no initial bereavement assessment completed. This was reviewed and validated with the Administrator.

Observed in Record Review. Identified 2 of 8 active patient records reviewed, the organization did not ensure the plans of care included all services needed for the palliation and management of the terminal illness and related conditions. For example in the record review of HV#2, it was identified that the patient was being treated for a wound that was identified approximately 3 months prior to the survey date, but the patient's nursing plan of care was not updated to include Skin for 7 weeks following the wound identification; and, in the record review for HV#3, a wound was identified upon admission approximately 3 weeks prior to the survey date, but there remains no Skin nursing plan of care. This was reviewed and validated with the Administrator and Director of Patient Care Services.

Observed in Record Review. In 8 of 8 active patient records reviewed, the organization did not ensure that the written plan of care (POC) included all services needed in the management of the terminal illness and related conditions. For example, identified in the record review for HV#1, there were no written spiritual or psychosocial POC developed since the start of care date approximately 4 months prior to the survey date. In the review of the record for HV#2 there was no written psychosocial POC developed since the start of care date approximately 8 months prior to the start of care date. In the record review for HV#3, it was identified that there was no psychosocial POC developed since the start of care date approximately 3 weeks prior to the survey date. In the review of RR#1 there was no written psychosocial POC developed since the start of care approximately 3 weeks prior to the survey. In the review for RR#2 there were no written psychosocial or spiritual POC developed since the start of care date approximately 3 weeks prior to the survey date. In the review for RR#3 it was identified that there was no written psychosocial POC developed since the start of care date approximately 5 weeks prior to the survey day. In the review for RR#4 it was identified that there was no written psychosocial plan of care developed since the start of care date approximately 8 months prior to the survey date. In the review for RR#5 it was identified that there were no written Spiritual or Psychosocial POC developed since the start of care date approximately 10 months prior to the survey date. This was reviewed and validated with the Administrator.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization did not reduce the risk of infections associated with medical equipment. For example in HV#1, the Registered Nurse (RN) did not clean the reusable medical equipment in accordance with the organization's policy No. 9-014.1,2 - Bag Technique. Observed during the visit, the RN used a stethoscope, manual blood pressure cuff, infrared thermometer, and a pulse oximeter to complete the patient's assessment. Following completion of the assessment, the RN used one individual alcohol prep pad to clean her stethoscope, but did not clean the other reusable medical equipment. This was reviewed with the Administrator and Director of Patient Care Services. Observed in Patient Home. In 1 of 3 home visits conducted the organization did use standard precautions to reduce the risk of infection. For example in HV#1, the Registered Nurse (RN) did not use standard precautions per organizational policies No. 9-009.1,2 Hand Hygiene, and No. 9-014.1,2 Bag Technique. Observed during the visit, the RN did not perform hand hygiene prior to donning gloves and beginning the patient's assessment. During the course of the assessment, the RN removed the gloves and used her mobile phone to access her email. Following using the mobile phone, she entered the clean area of the nurse bag without performing hand hygiene and retrieved a clean pair of gloves. She donned the clean gloves before approaching the patient's hospital bed area and stated I do not trust that the patient's skin is clean so I wear gloves. Following completion of the patient's assessment, the RN removed the gloves, and proceeded to the patient's bathroom to complete hand washing. The RN had no hand soap or paper towels with her, so she used the contents of the patient's unlabeled liquid pump dispenser to wash hands, turned off the faucets with her hands, and dried her hands on a cloth towel in the bathroom. This was reviewed and validated with the Administrator and Director of Patient Care Services.

Observed in Patient Home. In 1 of 2 home visits conducted where the skilled nurse completed a medication reconciliation, the patient's medication profile was not accurate. For example, in HV#1, the patient's medication profile listed Melatonin 5mg tablet, 1 tablet at bedtime as needed, however the patient stated this was not being taken. The medication profile listed Temazepam 15mg capsule, 1 capsule at bedtime as needed, however there was none in the home. The medication profile listed Benadryl 25mg capsule, take 1 at bedtime as needed, but the Benadryl was not in its original container but was found in an old pharmacy dispensed medication bottle with Benadryl written in marker across the label. The medication profile listed both Pepcid 20mg, 1 tablet twice daily, and Famotidine 20mg, 1 table twice daily, but there was none in the home, and, instead the patient was taking Nexium OTC which was not on the medication profile. This was reviewed and validated with the Administrator and Director of Patient Care Services.