Every finding on record at Hinds Hospice

Observed in Building Tour. The privacy curtains in the 3 patient bedrooms at the IPU did NOT have a label or documentation that the curtains met NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films, as required by NFPA 101-2012, 19.7.5.1 and 10.3.1. This was verified by the Safety Officer. The surveyor discussed the Life Safety deficiency with the organization, and it was determined that the following ILSMs will be implemented until the deficiency has been resolved and according to the organization's ILSM policy:

Based on interview and record review the agencys Director of Patient Care Services (DPCS) failed to follow the written policies and procedure titled, "Performance Evaluations" when Case Manager (CM) 1 did not receive a performance evaluation for three and six months after being hired on 1/8/2024. These failures had the potential for patients to not receive the necessary treatment and care by competent staff. --- During a concurrent interview and record review on 8/29/24 at 10:20 a.m., with DPCS, CM 1s personnel record was reviewed. CM 1s date of hire was 1/8/24. CM 1s personnel file did not contain performance evaluation for 3 months and 6 months. The DPCS stated, ";It is my duty to update the performance evaluation as scheduled. We did have role changes in the organization but since I am the DPCS as of March 2024 it is my duty to review CMs performance. [CM 1]s evaluation was not done." During a review of the agencys policy and procedure (P&P) titled ";Performance Evaluations" dated 08/2021, indicated, ";...After the initial three (3) month and six (6) month evaluation, performance evaluations are scheduled approximately every twelve (12) months, usually coinciding with the anniversary of the employees original date of time..." During a review of agencys job description for ";Executive Director of Clinical Services" dated 2/2024, the job description indicated, ";...Evaluating hospice services and personnel using measurable outcomes and objectives...Ensuring that appropriate service policies and procedures are developed and implemented to accomplish identified outcomes..."

Observed in Record Review. During HV#1-5, RR#1-15 it was noted the consent lacked a portion of the addendum form for patient notification of non covered items, service, or drugs. The addendum in the record lacked the additional language for the patient to choose or decline the information. This was discussed with the clinical leadership. This was corrected onsite during the survey.

Observed in Record Review. In 2 of 20 patient records reviewed, During RR#6 and RR#10 it was noted the chaplain (SCC) did not complete an initial assessment within 5 days of the RN initial assessment. There was lack of documentation of the reason for the delay. This was discussed with the clinical leadership.

Observed in Record Review. In 3 of 20 patient records reviewed, During HV#5, RR#6 and RR#13 record reviews it was noted lack of documentation of an initial bereavement assessment. This was discussed with clinical leadership.

Observed in Record Review. In 6 of 20 patient records reviewed, During HV#4 it was noted the organization did not update the POC to consider changes that had taken place since the initial assessment. During HV#4 record review it was noted a Music Therapy (MT) visit was performed the end of April 2022. There is lack of an update at the next IDG the beginning of May 2022 to include MT on the IDG/POC. During RR#2 it was noted the IDG/POC was not updated during IDG meetings. The summaries from the RN, MSW and SCC were the same for 4 IDG/POC updates reviewed. During RR#4 it was noted the comprehensive assessment was not updated by the social worker (HSW) or the chaplain (SCC) and the summaries were identical for the 2 IDG meeting the end of May and the beginning of June 2022. During RR#5 the HSW summaries were identical at each IDG since the initial IDG/POC meeting. There was lack of summary updates documented by the SCC at any of the IDG meetings to date. During RR#8 it was noted lack of documentation from the SCC at IDG meetings. The HSW documentation was the same at consecutive IDG meetings. During RR#12 it was noted the SCC did not document during the IDG meetings as part of the comprehensive assessment. During RR#13 it was noted the HSW and SCC summaries at IDG meetings were identical to the summaries from prior IDG meetings.

Observed in Record Review. In 2 of 20 patient records reviewed, During RR#1 it was noted the medical record was not accurately documented. The record contained a death visit summary completed the beginning of June with the patient's name identified but the documentation reflected the assessment of a different patient. The patient did not expire on the date documented. This finding was corrected during the survey by the IDG members. During RR#7 it was noted an order for O2 therapy on the medication profile and oxygen safety was listed under safety measures. The SN documented in the first IDG meeting that there was no oxygen in the home. The initial RN assessment documents oxygen at 2L/PRN SOB. No oxygen was documented in the next comprehensive RN assessment. This was discussed with clinical leadership.

Observed in Record Review. In 1 of 20 patient records reviewed, During RR#2 it was noted on the respiratory section of the POC the documentation Impaired gas exchange related to generalized weakness as evidence by shortness of breath, requiring oxygen therapy at 2LPM as needed and use of accessory muscle. The order for oxygen therapy was not included on the medication profile or as part of the respiratory intervention section of the POC. This was discussed with clinical leadership. Observed in Record Review. In 3 of 20 patient records reviewed, During RR#8 it was noted the documentation by the RN at an IDG meeting in May 2022 documented the patient has been put on macrobid for symptoms of UTI by her primary care physician, writer will make visit and update med on pt’s med profile and assess if pt has any symptoms. The GU problem identified with interventions and outcomes were not added to the POC and Macrobid was not added to medication profile. This was discussed with clinical leadership. During HV#1 record review it was noted at the IDG meeting the end of April, the documentation from the RN on the POC summary stated Pt placed on imminent list due to not eating and drinking for the past four days and refusing to take medications today. The POC was not updated to include assessing, establishing interventions and goals to address the change in condition. During RR#9 it was noted the RN summary documentation during IDG: pt recently treated with oral antibiotic for UTI, pt also having increased anxiety/agitation, routine ativan added. Pt has a boil to her left armpit, facility staff instructed to apply warm compression, family does not want pt to be treated with oral antibiotic, no drainage noted to site. The POC was not updated to reflect the change in condition and a physician order for application of compresses was not documented on the POC.

Observed in Record Review. In 4 of 20 patient records reviewed, During HV#4 record review it was noted the chaplain (SCC) visits were 1x/month with 3 PRN visits for spiritual distress on the IDG POC. There is lack of documentation of a visit in April 2022. During HV#5 record review it was noted a frequency for the SCC on the IDG POC of 1x/month. There is lack of documentation of SCC visits from the beginning of April 2022. The SCC documented 2 phone calls to the daughter to attempt to visit the patient. The POC was not updated to reflect the attempts by the SCC. During RR#4 it was noted the frequency for the chaplain (SCC) 1x/month was not followed. There is lack of documentation of a visit provided in April 2022. During RR#5 it was noted the SCC frequency on the POC was 1x/month. There were documented phone calls from the SCC with patient visits needed to be scheduled and a month later a phone call indicating monthly phone calls were being scheduled. There is lack of documentation that visits would be scheduled as phone visits or if actual phone visits had taken place. During RR#13 it was noted on the POC an order for volunteer visits 2x/month starting the middle of April 2022. There is lack of documentation of volunteer visits completed and lack of an update to the IDG. This was discussed with clinical leadership.

Observed in Record Review. During HV#1 record review it was noted the oxygen order on the medication profile was O2 at 2L/min PRN SOB. The SN documented on the POC summary the Pt remains on 2.5 L of oxygen via NC. The SN checked the liter flow during the home visit and stated the liter flow was 2.5L/min continuous. This was discussed with clinical leadership.

Observed in Patient Home. In 2 of 5 home visits conducted, During HV#1 it was noted the SN did not follow accepted standards of practice to prevent transmissions of infection and did not adhere to the organization Hand Hygiene Policy # 8455121. Upon completion of wound care the SN did not remove her gloves and disinfect her hands prior to the using her cell phone and placing it in her pocket. In addition the SN, when the wound care procedure was completed, did not remove her gloves and disinfect her hands prior to disinfecting the scissors, and tape measure used during wound care. During HV#4 it was noted the SN after completing documentation in the home using her tablet, disinfected the tablet and placed it immediately back into her bag. The disinfectant used requires a 1 minute contact time to dry for disinfection. This was discussed with clinical leadership. Observed in Patient Home. In 1 of 5 home visits conducted, During HV#1 it was noted the SN did not follow standards of practice to prevent the transmission of infections as outlined in the organization Bag Technique Policy # 9397125. The SN did not remove her gloves and disinfect her hands after providing patient care before choosing and gathering wound care supplies from the patient's closet. This was discussed with clinical leadership.

Observed in Record Review. In 4 of 20 patient records reviewed, During HV#1 record review it was noted the aide assignment form did not indicate the oxygen order on the POC. The direction within the special Instruction section was documented: O2 may be removed briefly for personal care - reapply once complete. The oxygen use (specify) part of the form was blank. During HV#2 record review it was noted in May 2022 an oxygen safety assessment completed during an SN visit. The aide assignment form was not updated to include oxygen safety precautions for the aide to observe and did not include the oxygen order under the special instruction oxygen use (specify). During RR#9 it was noted the aide assignment documented oxygen at 3L continuous. There is lack of direction to the aide if the oxygen can be removed during personal care or to remain in place during care. During RR#12 it was noted a frequency for the aide of 2x/week without an aide assignment form completed by the RN. The aide visits the patient 2x/week. This was discussed with clinical leadership.