Every finding on record at Holding Hands Hospice

Upon patient record review, 1 of 14 (Patient #10) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #10 Start of care 04/19/24, passed at home 04/21/24. Initial nursing comprehensive assessment notes patient is Imminently dying. There is not further evidence of any nursing visit, not even a death visit/note. The Discharge summary states, "TOD 12:11am".

Upon patient record review, 5 of 14 (Patient #5,6,9,10,13) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient #5 No SCP signature for the following IDG notes:09/26/23, 10/10/23, 10/24/23. The discipline was actively involved with the patient therefore there was no evidence of collaboration since there was no signature to validate participation. Patient #6 No SCP signature for the following IDG notes: 11/30/23. The discipline was actively involved with the patient therefore there was no evidence of collaboration since there was no signature to validate participation. Patient #9 No RN signature for the following IDG notes: 09/03/24, 09/10/24, 09/24/24. The discipline was actively involved with the patient therefore there was no evidence of collaboration since there was no signature to validate participation. Patient #10 No RN signature for the following IDG notes: 04/23/24. The discipline was actively involved with the patient therefore there was no evidence of collaboration since there was no signature to validate participation. Patient #13 No SCP signature for the following IDG notes: 02/22/24, 03/07/24. The discipline was actively involved with the patient therefore there was no evidence of collaboration since there was no signature to validate participation.

Upon patient record review, 2 of 14 (Patient #6,13) did not have evidence the hospice offers bereavement counseling that includes: • Making bereavement services available to the family and other individuals in the bereavement plan of care up to 1 year following the death of the patient. Bereavement counseling also extends to residents of a SNF/NF or ICF/IID when appropriate and identified in the bereavement plan of care • Ensuring that bereavement services reflect the needs of the bereaved • Development of a bereavement plan of care that notes the kind of bereavement services to be offered and the frequency of service delivery Patient #6 passed 12/17/23. A "Condolence call" was completed by Bereavement Coordinator on 12/18/23 with a note stating, emotional support provided and family made aware of "Spiritual care service available upon request". No evidence of a Bereavement Plan of Care. No evidence of mailings. Patient # 13 passed 02/29/24. Discharge summary per RN states, "Bereavement care offered for 13 months". No evidence of any Bereavement care provided.

Upon personnel record review, 1 of 12 (Personnel #6) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(B) Sponge bath The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel 6: The aide competency did not contain evidence of the aide performing a sponge bath.

Observed in Record Review. In 2 of 2 patient records reviewed, who had documented IDG meeting notes. During HH#2 and HV# 3 record reviews, it was noted the comprehensive assessments were not updated during the IDG meetings. The documentation was completed by checking the no box that stated during the past 15 days has the patient experienced any changes in physical needs, psychosocial needs, emotional needs and spiritual needs. The no box was checked for the RN, MSW and Chaplain members of the IDG. This was discussed with the DPCS designee.

Observed in Record Review. During RR#1 it was noted one SN clinical note in the MR was dated 2 months after the patient revoked the Hospice benefit. This was discussed with the DPCS designee.

Observed in Record Review. In 5 of 5 patient records reviewed, During RR#1 it was noted goals on the POC that were not measurable and not individualized. For example: patient will receive optimal teaching and support as cardiac and pulmonary functions change during care, skin will be maintained at an optimal level during care, promote optimal nutrition/hydration. During RR#2 it was noted goals that were not measurable or individualized. For example: Patient caregiver will achieve optimal grief reaction prior to patient's death, skin will be maintained at an optimal level, optimal hygiene will be maintained. During HV#1 it was noted goals that were not measurable and not individualized. For example: optimum hygiene will be maintained during care, skin will be maintained at an optimal level during care During HV#2 it was noted goals that were not measurable and not individualized. For example: Pt will maintain optimal mobility during care within 2 wk period of time, optimal hygiene will be maintained during care. During HV#3 it was noted goals that were not measurable and not individualized. For example: patient will maintain optimal mobility during care within 2 weeks, patient/caregiver will achieve optimal grief reaction prior to patient's death. This was discussed with the DPCS designee.

Observed in HR File Review. During review of HR#10, it was noted lack of documented initial competencies. The employee completed a self appraisal of skills without validation of skills by persons who were educationally trained or equivalent to assess competency.