Every finding on record at Hernando Pasco Hospice Inc

Based on interview and record review facility failed to have up to date background screenings for 1 volunteer out of 3 volunteers reviewed for staff files. --- Based on interview and record review facility failed to have up to date background screenings for 1 volunteer out of 3 volunteers reviewed for staff files. Findings include: Review of Staff A Volunteer Agency of Healthcare Administration background screening retained prints expiration date was 1/8/2024. Review of Staff A Volunteer Assignment sheet, last assignment was on 2/27/2024 for a veteran's program. Review of Staff A Assignment Position Description Job Title Patient-Family Volunteer revision dated 6/17 reads, ";Volunteer Requirements: Successful pass background screening as required for position (Level I and Level II)." During an interview on 4/10/2024 at 10:46AM with Staff B Volunteers Manager stated, ";When prints expire volunteers will not be allowed to go out to the field. Staff A fingerprints are expired." During an interview on 4/10/2024 at 12:22PM with Chief Compliance Officer stated, ";The Volunteer Coordinator should be monitoring that volunteers do not go out of meeting the requirements. The list provided were volunteers considered to be active and able to go out." Review of the facility policy and procedure titled ";Background and Criminal Screening for Employment" with an effective date of 12/08/202 reads: Policy: It is the policy of the above Organization(s) to assure that employment and volunteer candidates, employees volunteers, independent contractors and temporary agency staff receive and maintaining satisfactory results from criminal and other background investigation, as required for their position in order to perform work for chapters health system. Procedure: D. In accordance with section 408.809 (2), Florida Statutes, all Company entities shall conduct appropriate criminal background re-screening of individual in the position identified above at least every five years."

Observed in Record Review. In 1 of 5 patient records reviewed, the Surveyor noted the RN had not completed a comprehensive visit every 15 days. For example, in RRNHV #1, there had been 19 days between RN comprehensive visits. This was validated with the Chief Compliance Officer.

Observed in Record Review. In 1 of 23 patient records reviewed, it was noted in RRNHV#7 that the Spiritual Counselor did not within 5 days. Additionally there was only a phone call documented on day 7 and as of this date there had been no SC visit made. This was confirmed by supervisor assisting with record review.

Observed in Patient Home. In 1 of 6 patient records reviewed, the Hospice did not re evaluate for medication changes after admission. RR#2 resided in an assisted living facility and the Hospice RN did not evaluate for changes to the medication schedule. Based on review of the medication administration profile of the facility, the patient was placed on a pain medication one week ago and this medication was not listed on the Hospice medication profile. Per the compliance RN, the patient was visited by the RN one day ago and the Hospice medication profile had not been updated.

Observed in Record Review. In 2 of 23 patient records reviewed, it was noted in RRNHV#1 that there were no orders in the plan of care for frequency at the start of care. For example, visit frequencies listed on the IDT of early June had a start day for late July. Additionally for this patient there were no orders for insertion of a midline catheter for Zosyn IV and no orders to discontinue the line. In another example, in RRNHV#2 there are no orders to discontinue aide services although the aide had not seen the patient for weeks and the SN documented in her notes that the visits were to be discontinued. In another example, in RRNHV#8 there were no orders for application of ATB ointment to patient toe and no order for leaving a foot wound open to air. Observed in Record Review. In 1 of 23 patient records reviewed, it was noted in RRNHV#13 that the LPN visits were ordered as needed. There was no number to quantify and no reason to qualify the visits. This was discussed with the Compliance Director. Observed in Record Review. In 1 of 23 patient records reviewed, it was noted in review of RRNHV#9 that there was no order for a change in level of care. For example, the patient was returned to routine home care following a 5 day respite stay in the hospice house. This was discussed with the Compliance Director.

Observed in Individual Tracer. The Hospice medication profile reflected multiple duplications of prn medications without qualifications in RR#1. For the symptom of pain, there were two different medications listed specifically acetaminophen and morphine. Similarly, for the symptom of nausea there were two medications listed. This observation was discussed with the compliance RN, Observed in Record Review. In 1 of 23 patient records reviewed, it was noted that in RRNHV#10 there were multiple PRN medications with no specific indications for example, Ibuprofen 800 mg every 8 hours for pain, and Oxycodone 10 mg every 4 hours PRN non-acute pain. Observed in Record Review. In 1 of 23 patient records reviewed, it was noted that in RRNHV#9 there were multiple PRN medications with no specific indications. For example, Morphine Sulfate 20 mg every 4 hours for non acute pain and Morphine Sulfate 7.5 mg every 2 hours PRN for pain. This was discussed with the Compliance Director. Observed in Tracer Activities. While observing a medication administration, the compliance manager confirmed that the patient's medication list had two different doses of fentanyl ordered for pain without differentiating when to give which dose.

Observed in Record Review. In 4 of 23 patient records reviewed, it was noted that the plan of care was not updated or revised when the patient condition required change. For example, in RRNHV#1 the plan of care was not updated for insertion of a midline catheter for Zosyn IV or to discontinue the line. In RRNHV#2 the plan of care was not updated to reflect the lack of need for aide services after the aide had been refused for 5 weeks. Additionally, the plan of care was not updated to include the development of a new wound. In another example, in RRNHV#3 the plan of care was not updated to include ongoing 3 + edema to BLE and LUE and was not updated to include Aspira drain placement for removal of abdominal fluid. In another example, in RRNHV#5 it was noted that the plan of care was not updated when a wound developed nor when the wound care orders were subsequently changed and was not updated when the patient developed thrush. This was discussed with the Compliance Director. Observed in Record Review. In 1 of 23 patient records reviewed, it was noted that the plan of care was not updated or revised to include 3+ pitting edema from ankles to hips as described in skilled nursing documentation.

Observed in Record Review. In 2 of 23 patient records reviewed, it was noted in RRNHV#8 that there were orders to increase skilled nurse visit to 2 times per week in late September however visits have only been provided weekly since then. Additionally in this record there was no skilled nurse visit for one week in late September and no documentation of missed visit. In another example, in RRNHV#13 there was no weekly RN visit provided for the middle of October and no documentation of a missed visit. This was confirmed by the Compliance Director. Observed in Record Review. In 1 of 23 patient records reviewed, it was noted in RRNHV#11 that in May the MSW visit frequency was stated as monthly however there were no visits made for June, July, August, Sept. and no documentation of missed visits. This was verified by the Compliance Director.

Observed in Record Review. In 1 of 23 patient records reviewed, it was noted in RRNHV#7 that there was no documentation of a change in wound status reported to the physician. For example, documentation in the Skilled Nurses note one day after the admission assessment stated that the wound was draining serous, serosanguinous drainage and had an odor. This was a change in condition from prior day's documentation. This was confirmed by the Compliance Director.

Observed in Individual Tracer. In 1 of 6 home visits conducted, the hospice did not comply with the policy titled -Bag Technique which indicated that reusable equipment would be cleaned at the conclusion of the visit. The RN in RR#1 was observed cleaning her equipment after each use. For example, after taking the patient's blood pressure she cleaned the cuff off, after pulse ox she cleaned the device off etc. and placed the cleaned equipment in a designated clean area. The RN also dropped a used wipe in the designated clean area along with her cleaned equipment. This observation was discussed with the compliance RN. Observed in Individual Tracer. In 1 of 6 home visits conducted, the Hospice did not comply with the policy titled - Hand hygiene. The hospice aide in RR#4 was observed closing the faucet off with her hands after washing them. This observation was discussed with the compliance RN. Observed in Tracer Activities. While observing a medication administration, the compliance manager confirmed that the nurse had not performed hand hygiene prior to drawing up the IV medications as stated in their hand hygiene policy.

Observed in Record Review. In 2 of 23 patient records reviewed, it was noted in RRNHV#4 that the aide consistently did not provide a shave for the male patient although this task was assigned by the RN. There was no documentation that the RN was notified to update the aide assignment. In RRNHV#2 the aide did not perform oral care, shave, back care and shampoo in 3 of 3 visit notes. There was no documentation that the RN was notified to update the aide assignment. Additionally for this patient the aide visit was refused either after her arrival or as a missed visit in 13 visits. Again there was no documentation that the RN was notified. In another example, RRNHV#9 it was noted that in 2 of 4 aide visit notes the aide performed a bed bath because the patient was unable to ambulate to to the shower. The aide care plan stated that a shower was to be given each visit. There was no documentation that the RN was notified. This was discussed with the Compliance Director. Observed in Record Review. In 1 of 23 patient records reviewed, it was noted in RRNHV#6 that on two aide visit notes there was no bath or dressing documented as being provided. Additionally, on 3 of 3 other visit notes for the aide there was no documentation that shave, oral care, skin care or shampoo were provided and there was no documentation of the reason or that the skilled nurse had been notified. This was confirmed by compliance director.

Observed in Record Review. In 1 of 23 patient records reviewed, it was noted in RRNHV#7 that the nurse did not document how the wound was cleansed. There were orders for wound cleanser however all of the SN notes reviewed simply stated, cleansed wound. This was discussed with the Compliance Director. Observed in Record Review. In 2 of 23 patient records reviewed, during review of RRNHV#1 it was noted that there was no documentation in the record of any lab results related to multiple urinary tract infections for which the patient was treated. Urine specimens were ordered two different times and there was no documentation of the results. In another example, in RRNHV#12 it was noted that the chaplain made a visit in September which contained no narrative or details of his visit or care provided. This was discussed with the compliance director.

Observed in Record Review. In 1 of 21 patient records reviewed, it was noted in RRNHV #1 that there was no initial certification by the attending physician. This was discussed with the compliance director.

Observed in Individual Tracer. In 2 of 6 home visits conducted, of patients with oxygen, the Hospice did not manage safety risks. The surveyor observed oxygen cylinders standing up right and not secured in a holder in RR#3 and RR#4 and there was no documentation in the records of reeducation related to this risk. This observation was discussed with the compliance RN.

Observed in Record Review. In 1 of 23 patient records reviewed, it was noted that in RRNHV#1 there was no documentation of a care plan that identified the care and services that are needed and specifically identify which provider is responsible for performing the respective functions that have been agreed upon. This was discussed with the Compliance Director.

Observed in Record Review. In 1 of 23 patient records reviewed, it was noted that in RRNHV#1 there was no documentation of a care plan that reflected the participation of the hospice when the patient was hospitalized or when the patient had a midline catheter placed by the SNF Physician Assistant. Additionally there was no discontinue order in the hospice record for the midline. This was discussed with the Compliance Director.

Observed in Individual Tracer. In 1 of 1 patient records reviewed, the Hospice did not provide the nursing home with all of the required hospice documents. A review of RR#5's chart, who resided in a nursing home, did not include the CTI and or the most recent IDG. The last IDG in the nursing home record was dated for over a month ago. This observation was discussed with the RN of compliance.

Observed in Building Tour. During the building tour, the facilities director confirmed that the piping for approved automatic sprinkler systems was supporting other items, as evidenced by coiled conduits resting on a sprinkler pipe. Corrected onsite. This finding was observed during survey activity, but corrected onsite prior to the surveyor's departure. The corrective action taken needs to be included in the organization's Evidence of Standards Compliance submission.

Observed in Building Tour. During the building inspection, the facilities director confirmed that 4 empty oxygen tanks were in the rack marked full inside the clean utility room. Corrected onsite.

Observed in Building Tour. The nurse manager and EVS manager confirmed that the organization did not have a process for disinfecting or sanitizing the residential clothes washers in the IPU between use. Observed in Building Tour. The nurse manager and EVS manager confirmed that the organization had not been performing a disinfection or sanitization of the residential clothes washer in the IPU between use. Observed in Building Tour. The nurse manager and EVS manager confirmed that the organization had not been performing a disinfection or sanitization of the residential clothes washer in the IPU between use.

Observed in Building Tour. During the building tour, the nurse manager confirmed that four containers of nutritional supplement (Jevity) in the clean utility were found to be expired by one week.