Every finding on record at Holzer Hospital Foundation

Observed in Record Review. In 6 of 6 patient records reviewed, During the record review, the hospice surveyor noted that the EMR did not allow for goal dates on the plan of care. This was validated in a discussion with and observation by the Director of Hospice.

Observed in Regulatory Review. During the record review for the home visits, in RRHV1 the hospice nurse surveyor noted that the there was no reason for the PRN visits listed for the MSW. In RRHV2, there was no reason stated for PRN visits by the Chaplain. In RRHV3, there was no reason indicated for the PRN visits by the MSW. n RR 4 there was no prn reason for the PRN visits by the MSW. This was validated in a discussion with and observation by the Director of Hospice and the Quality scribe.

Observed in Data Session. The organization failed to have a QAPI program that reflected the complexity of the organization and its services. During tracer activities for Data Management, the surveyor observed the QAPI program, for both home care and hospice, did not involve all services provided as evidenced by the HCO was not able to produce this documentation at the time of survey. For example the hospice QAPI program did not address palliative outcomes or all services being provided such as bereavement and volunteer. For home care the QAPI program did not address hospitalization, rehospitalization, or emergency services. This was discussed and reviewed with the Hospice Leadership Teams. Observed in Data Session. LD.03.07.01 EP5 The organization failed to have an effective, ongoing, organizational wide, data driven quality assessment and performance improvement program. During tracer activities for Data Management, the surveyor observed the organization did not have an effective, ongoing, organization wide, data-driven QAPI program as evidenced by the HCO was not able to produce this documentation at the time of survey. This was discussed with the Home Care Team and Hospice Team.

Observed in Tracer Activities. The organization failed to maintain a QAPI program that demonstrated improvement in the indicators related to improved palliative outcomes and hospice services. During tracer activities related to Hospice for Data Management, the surveyor observed the QAPI program did not demonstrate improvement in its palliative outcomes and hospice services as evidenced by the HCO was not able to provide documentation at the time of survey. This was discussed and reviewed with the Hospice Leadership Teams.

Observed in Tracer Activities. The organization failed to use its quality indicator data in the design of its quality assessment and improvement program. During tracer activities for Data Management related to Hospice, the surveyor observed the hospice did not use patient care indicator data in the design of its quality assessment and improvement program as evidenced by the HCO was not able to produce this documentation at the time of survey. This was discussed and reviewed with the Hospice Leadership Teams.

Observed in Tracer Activities. The organization failed to compile and analyze data over time. During tracer activities for Data Management, the surveyor observed the organization did not analyze and compare data over time to identify levels of performance, patterns, trends and variations as evidenced by lack of documentation during survey. This was discussed and reviewed with the Hospice Team.

Observed in Data Session. The organization failed to maintain documentation that the governing body approved the frequency and detail of data collection. During tracer activities for Data Management , for home care and hospice, the surveyor observed the organization was collecting data the frequency was not approved by the governing body. This was discussed and reviewed with the Home Care Leadership Team.

Observed in Tracer Activities. The organization failed to select performance improvement activities that affect palliative outcomes, patient safety, and the quality of care that are based on high-volume, high-risk, problem-prone areas. During tracer activities for Data Management related to Hospice, the surveyor noted the hospice did not select performance improvement activities that affect patient safety, palliative outcomes or that were high-volume, high-risk, problem-prone areas as evidenced by the HCO was not able to produce this documentation at the time of survey. This was discussed and reviewed with the Home Care and Hospice Leadership Teams.

Observed in Tracer Activities. The organization failed to establish priorities for data collection. During tracer activities for Data Management, the surveyor observed, for both home care and hospice programs, the organization had not developed a data- based performance improvement program, hence leadership did not set priorities for data collection. This was discussed and reviewed with the Home Care and Hospice Leadership Teams. Observed in Data Session. The organization failed to establish priorities for performance improvement. During tracer activities for Data Management, the surveyor observed performance improvement was not organization wide as evidenced by lack of documentation during survey. This was discussed and reviewed with the Home Care Team and Hospice Team.

Observed in Individual Tracer. In 1 of 4 home visits conducted, During HV 4, the hospice surveyor noted that the aide did not change her gloves after showering the patient and completing the peri care area and began to dry the patient with the contaminated gloves. This was validated in a discussion with and observation by the Clinical Coordinator for Hospice.

Observed in Individual Tracer. In 2 of 2 where aide services were provided, During the record review HV 1 and 4, the hospice surveyor noted that the organization did not assess and documents whether the aide followed infection control policies. This was validated in a discussion with and observation by the Director of Hospice.

Observed in Record Review. In 6 of 6 patient records reviewed, During the record review, the hospice surveyor noted that there were incomplete medical records. For example, the electronic medical record did not save initial bereavement assessments, Morse fall risk assessments or aide supervisory visit questions. This was validated in a discussion with and observation by the Director of Hospice.

Observed in Record Review. In 2 of 2 patient records reviewed, During the record review for 2 live discharges, the hospice surveyor noted that the organization did not ensure that the discharge summary and instructions were complete with a summary of care and that a med list was included. This was validated in a discussion with and observation by the Director of Hospice.