Every finding on record at Heritage Hospice, LLC,

Observed in Record Review. In 1 of 14 patient records reviewed, the hospice had not conducted and documented a patient-specific comprehensive assessment that identified the patient’s need for hospice care and services. In the chart for RRNHV#7, there was no comprehensive pain assessment completed as a part of the comprehensive assessment, despite the patient having identified pain and having MS Contin active at the admission. This was discussed with the Administrator.

Observed in Record Review. In 4 of 14 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 RRHV#1, the patient was at risk for falls, experienced a fall, yet the plan of care did not have a goal related to education and implementation of individualized fall prevention strategies. In the chart for RRNHV#6, for the patient with pain as an active/anticipated problem, the target date for the pain management goal of the patient/caregiver will verbalize an understanding of the pain management program was the end of first benefit period. In the chart for RRHV#3, music therapy was added to address the patient's social isolation, yet there was no goal for music therapy. In the chart for RRNHV#9, the goal anticipated target dates were not appropriate to the problem. Patient /family will express satisfactory control of symptoms with a target date as the last day of the benefit period. This was discussed with the Administrator.

Observed in Record Review. In 1 of 14 patient records reviewed, the plan of care did not include a detailed statement of the scope and frequency of services. In the chart for RRHV#1, the IDG notes indicated that the Spiritual Counselor was planning to continue to make contact with the patient for further needs, however the plan of care was not updated to reflect a type or frequency of services beyond the evaluation visit. This was confirmed with the Administrator.

Observed in Record Review. In 6 of 14 patient records reviewed, the plan of care did not includes all services needed for the palliation and management of the terminal illness and related conditions. In the chart for RRHV#1, the patient was assessed to be at high risk for falls and also identified as having fall prevention measures in place upon admission such as fall pads, geri-chair, hoyer lift, etc., yet the plan of care did not include these interventions. The patient experienced a non-injury fall less than one week post admission. In addition, the plan of care included incomplete orders as Senna, Bisacodyl and Polyethylene glycol were all ordered prn for constipation yet did not include further clarification as to when to administer which medication. In the chart for RRNHV#4, the oxygen order was not on the initial plan of care. In the chart for RRHV#2, Tylenol and Oxycodone were both ordered prn for pain with no further clarifying direction. In the chart for RRHV#3, the patient was assessed to be at risk for pressure ulcer development and falls. There were no interventions for pressure risk reduction measures nor fall prevention on the plan of care. Additionally, the scale Insulin order was missing the frequency of administration. In the charts for RRNHV#9 and RRNHVD/C#11, there was no order for oxygen on the POC. This was confirmed with the Administrator.

Observed in Record Review. In 2 of 2 patient records reviewed, for bereavement services, the hospice had not developed a bereavement plan of care that specified the type of bereavement services to be offered and the frequency of service delivery. In the charts for RRBR#13 and RRBR#14, while bereavement interventions and contacts were being documented as they occurred based upon the risk assessment, there was no written bereavement plan of care. It was not the current process of the hospice to create bereavement plans of care, simply to document activities as they occurred during the bereavement admission. This was discussed with the Administrator.

Observed in HR File Review. In 1 of 8 HR files reviewed, staff competence was not initially assessed and documented as part of orientation. During the survey it was noted that the aide had been assigned to trim the nails of a diabetic patient. Upon discussion, the surveyor was informed that this is within the scope for CNA's in the state. However, there was no documented competency evaluation of this skill within the HR file for the aide. This was discussed with the Administrator. Observed in HR File Review. In 1 of 1 HR files reviewed, for a hospice aide, the supervisor had not evaluated the following areas by observing a home health or hospice aide's performance of the tasks with a patient or pseudo-patient as part of a simulation: - Communication skills, including the ability to read, write, and verbally report clinical information to patients, caregivers, and other staff - Reading and recording temperature, pulse, and respirations - Appropriate and safe techniques in personal hygiene and grooming that include bed, sponge, tub, or shower bath; sink, tub, or bed shampoo; nail and skin care; oral hygiene; toileting and elimination - Safe transfer techniques and ambulation - Normal range of motion and positioning. In the file for HR6, the initial aide competency documentation form indicated that all of the competencies had been verified via verbalization rather than direct observation. This was discussed with the Administrator.

Observed in HR File Review. In 1 of 1 HR files reviewed, for a hospice aide, a registered nurse had not made an annual on-site visit to the location where the patient is receiving care in order to observe and assess each aide while the aide is providing care. This documentation was missing in the file for the aide.

Observed in HR File Review. In 1 of 8 HR files reviewed, there was no documentation in the HR file of annual infection control and blood borne pathogen education. In HR6, there was no documentation of annual education about blood borne pathogens and infection control. This was validated with the Administrator.

Observed in Record Review. In 1 of 14 patient records reviewed, the patient record did not contain the following clinical information: a list of medications including dose, strength, frequency, route, date and time of administration for prescription and nonprescription medications, herbal products, and home remedies that relate to the patient's care, treatment, or services. During HV#3, during the medication reconciliation, it was found that the Insulin order remained on the hospice plan of care, yet had been discontinued and did not appear on the current list in the SNF. This was discussed with the Administrator.

Observed in Record Review. In 1 of 2 patient records reviewed, for a live discharge, the hospice discharge summary did not include the following: a summary of the patient’s stay, including treatments, symptoms, and pain management; the patient’s current plan of care. There was no summary of the patient's stay on the discharge summary in the chart for RRNHVD/C#11. This was discussed with the DPCS.

Observed in Document Review. In 1 of 3 contracts reviewed, the written agreement with an outside agency providing contracted services for the hospice did not include a stipulation that the outside agency will complete criminal background checks on contracted employees who provide direct patient care or have access to patient records. This stipulation was missing in the contract for pharmacy services as confirmed with the Administrator.

Observed in HR File Review. In 1 of 8 HR files reviewed, the organization had not obtained a criminal background check on the applicant as required by law and regulation or organization policy. Criminal background check was not documented in the file for HR3 until the date of the survey; the individual had been employed by the organization for eleven months. This was discussed with the Administrator.