Every finding on record at Holy Care Hospice Inc.

Observed in Record Review. In 1 of 9 patient records reviewed, It was noted by the nurse surveyor that the initial bereavement risk assessment had not been completed as part of the comprehensive assessment. For RRNHV#2, the initial bereavement risk assessment was not completed. Findings were verified by the For Findings were verified by the CEO/Administrator and the QAPI Director.

Observed in Record Review. During record review surveyor noted that the plan of care goals were not written based on the patient’s goals and the time frames required to meet those goals. For example: a care plan problem for constipation was written with a goal to facilitate bowel elimination and comfort, patient and family will verbalize understanding of symptoms, but no measurable outcome and timeframe was indicated for goal attainment was written. This was reviewed and confirmed with the organization's Administrator/CEO.

Observed in Patient Home. In 3 of 9 patient records reviewed, it was noted by the nurse surveyor that medication orders were not clear or complete. For RRHV#1, the patient had two medications ordered for pain without indications for when to give which medication. Tylenol 500mg was ordered every 6 hours as needed for pain, Tramadol Hydrochloride 50mg 1 tab two times a day as needed for severe pain. Patient was also on two standing orders for additional pain medication Meloxicam and a standing dose of Tylenol. For RRNHV#1, order for Tylenol 500mg 1/1 cap po for mild pain every 4 to 6 hours and an order for Tylenol 500mg 2/2 caps for severe pain every 4 to 6 hours with no maximum dosage indicated. For RRNHV#2, the order for oxygen was 2-4 liters per minute BNC without instructions for titration. For Findings were verified by the CEO/Administrator and the QAPI Director.

Observed in Record Review. In 2 of 4 record reviews surveyor noted that discharge orders had not been entered. This was reviewed and confirmed with the organization's Administrator/CEO.

Observed in Patient Home. In 1 of 2 home visits surveyor observed the aide using a gait belt to aid with transferring the patient, but use of a gait belt was not on the plan of care. This was reviewed and confirmed with the organization's Administrator/CEO.

Observed in Record Review. In 1 of 4 record reviews surveyor noted that a discharge summary was not entered. This was reviewed and confirmed with the organization's Administrator/CEO.

Observed in Record Review. In 11 of 11 patient records reviewed, During review of the Admission packet, it was noted the organization had not provided the organization's policy on Advanced Directive. For example: the Admission packet had a patient handbook with general information regarding Advanced Directives with no specific information regarding the organization's Advanced Directives. This was reviewed and discussed with the Administrator and validated.

Observed in Record Review. In 3 of 11 patient records reviewed, During review of HV# 1, HV# 2, and RR# 4's patient records review, it was noted the organization had not ensured it maintained complete and accurate patient records. For example: review of the Updates to POC [plan of care/IDG[Interdisciplinary group, for HV# 1, HV# 2, and RR# 4, revealed no documentation of the last Updates to the POC/IDG from the last IDG meeting approximately five days prior to the surveyor review of the patient records. This was reviewed and discussed with the Administrator and validated.

Observed in Record Review. In 6 of 11 patient records reviewed, During HV# 1, HV# 2, HV# 3, RR# 1, RR# 2, and RR# 6's patient records review, it was noted the organization had not ensured the written plan of care was based on the patient's goals. For example: review of HV# 1, HV# 2, HV# 3, RR# 1, RR# 2's plans of care revealed the frequency for the Chaplain of one visit per month. However, review of the plans of care revealed no goals or interventions for the Chaplain. Review of RR# 1, RR# 2, and RR# 6's plans of care revealed the frequency for the medical social worker (MSW) of one visit per month. However, review of the plans of care revealed no goals. This was reviewed and discussed with the Administrator and validated. Observed in Record Review. In 2 of 11 patient records reviewed, During HV# 1 and HV# 3's patient records review, it was noted the plan of care goals were not individualized. For example: review of HV# 1's plan of care revealed HV# 1's terminal diagnosis was heart disease. Further review of the plan of care revealed a goal that HV# 1's blood pressure readings would be an individually acceptable range. However, further review of the plan of care revealed no documented individually acceptable range. Review of HV# 3's plan of care revealed a comorbidity of insulin dependent diabetes mellitus with a goal that HV# 3 would maintain optimal blood sugar level with no specific blood sugar level to evaluate. This was reviewed and discussed with the Administrator and validated.

Observed in Record Review. In 1 of 11 patient records reviewed, During HV# 3's patient record review, it was noted the plan of care had not included all interventions necessary to manage symptoms. For example: review of HV# 3's registered nurse comprehensive assessment revealed documentation of seizure precautions and anticonvulsant medication. Review of the IDG/Plan of Care revealed no documentation of seizure precautions. This was reviewed and discussed with the Administrator and validated.

Observed in Record Review. In 1 of 11 patient records reviewed, During HV# 3's patient record review, it was noted the plan of care had not included a statement of scope and frequency of all services necessary to meet the patient and family's needs. For example: the Spiritual Coordinator frequency on the plan of care included a visit frequency of every recertification and PRN [as needed] with no indication when an as needed visit would be provided. This was reviewed and discussed with the Administrator and validated.

Observed in Patient Home. In 1 of 3 home visits conducted, During HV# 2's home observation, it was noted the registered nurse (RN) had not followed the organization's Nursing Bag Technique policy, specifically, returning equipment to the nurse bag after cleaning the equipment. For example: during the home observation the RN performed vital signs with the blood pressure cuff, stethoscope, thermometer and pulse oximetry. The RN then placed the equipment in a zip lock plastic bag without cleaning the equipment and put the plastic bag in the nurse bag. This was observed and discussed with the Administrator and validated.

Observed in Record Review. In 2 of 2 patient records reviewed with home health aide services, During HV# 1 and HV# 2's patient record review, it was noted the registered nurse had not ensured the home health aide (HHA) written patient care instructions were complete. For example: review of HV#1's Aide Care Plan revealed the task of vital signs to be completed at each visit. Further review of the Aide Care Plan revealed no vital sign parameters. Review of HV# 1 and HV# 2's Aide Care Plan revealed the task of ROM: active - passive, with no further directions regarding active or passive range of motion. This was reviewed and discussed with the Administrator and validated.

Observed in Record Review. In 1 of 2 patient records reviewed with home health aide services, During HV# 2's patient record review, it was noted the organization had not ensured the home health aide (HHA) followed the Aide Care Plan. For example: review of the Aide Care Plan revealed the task of vital signs and to notify the registered nurse (RN) if the blood pressure reading was outside the parameters written on the Aide Care Plan. Review of the HHA visit notes revealed the blood pressure was outside of the parameters on 15 out of 17 visit notes reviewed. Further review of the HHA visit notes revealed no documentation the HHA contacted the RN to report the blood pressure that was outside the parameters. This was reviewed and discussed with the Administrator and validated.

Observed in Record Review. In 2 of 11 patient records reviewed, During RR# 1 and HV# 2's patient records review, it was noted the organization had not ensured the hospice medical director signed the certificate of terminal illness (CTI) at the time of recertification. For example: review of HV# 2's current re-certification CTI, beginning approximately 15 days prior to the surveyor review of the patient's record, revealed no signature from the hospice medical director/physician. Review of RR# 1's re-certification CTI, revealed the hospice medical director signed the CTI 12 days after the certification period began. This was reviewed and discussed with the Administrator and validated.

Observed in Record Review. In 1 of 11 patient records reviewed, During RR# 5's patient record review, it was noted the organization had not ensured all entries into the patient record were authenticated. For example: review of RR# 5's initial Certification of Terminal Illness (CTI) revealed it had been electronically signed by the licensed vocational nurse (LVN) and not a hospice physician. Further review of the CTI revealed the printed name of the hospice medical director and below the printed name was a hand written illegible signature with no date. This was reviewed and discussed with the Administrator that shared the CTI was signed in error by the LVN and the hand written signature that was not dated was from the alternate hospice medical director not the physician that was typed on the CTI.

Observed in Record Review. During the patient records review, it was noted all patients' electronic medical record (EMR) could be manipulated. For example: review of HV# 3's patient record revealed signed IDG/Plans of Care that were altered/manipulated. The Administrator shared an order to change the home health aide (HA) frequency was post dated, when the post dated order was entered into the EMR it changed the HA frequency order on the previously signed IDG/Plans of Care. This was reviewed and discussed with Leadership and validated.