Every finding on record at Hospice Alliance, Inc

Observed in Patient Home. In 1 of 3 home visits where oxygen was in use, the organization did not assess safety risks associated with oxygen cylinder storage. During home visit RRHV#3 cylinders were found in a closed closet and had been there since the patient was admitted seven months ago according to the patient’s daughter. This RFI was reviewed with the Executive Director and Director of Clinical Operations.

Observed in Record Review. In 1 of 18 active patient records reviewed, the organization did not conduct and document a patient-specific comprehensive assessment that identified the patient’s need for hospice care and services. In record RRNHV#3 a bereavement assessment was not documented. This RFI was reviewed with the Executive Director and Director of Clinical Operations.

Observed in Record Review. In 15 of 18 active patient records reviewed, medication orders in the plan of care were not specific. In record RRHV#2 there were 5 prn medications listed for treating constipation. These included Bisacodyl suppository, Docusate-Senna, Milk of Magnesia, MiraLAX, and Fleets enema. There was no clear direction for the order in which each medication should be used. Similar documentation was found in records RRHV#3, RRHV#4, RRHV#5, RRHV#6, RRNHV#1, RRNHV#2, RRNHV#3, RRNHV#4, RRNHV#5, RRNHV#6, RRNHV#7, RRNHV#8, RRNHV#9, and RRNHV#12. This RFI was reviewed with the Executive Director and Director of Clinical Operations.

Observed in Record Review. In 4 of 18 active patient records reviewed, certificates of terminal illness did not include subjective and objective information to support patient life expectancies of six months or less at recertification. For example, in record RRHV#2 physician statements were generic and there were no metrics in the 2nd CTI; in record RRHV#3 the 2nd and 3rd CTIs; in record RRHV#4 the 3rd, 5th, and 6th CTIs; and in record RRNHV#8 the 1st CTI. This RFI was reviewed with the Executive Director and Director of Clinical Operations.

Observed in Patient Home. In 1 of 4 home visits conducted, where medication reconciliation was performed the list in the home was inaccurate. During the visit for RRHV#3 the daughter stated that the patient had not used Docusate-Senna, Duloxetine, Famotidine, Sertraline, and Scopolamine for 6 months or more, but they were still listed on the current treatment administration record. This RFI was reviewed with the Executive Director and Director of Clinical Operations.

Observed in Document Review. There was not documented inspection and testing of fire door assemblies by a qualified person. This was verified by the executive director. Observed in Building Tour. In the fire sprinkler riser room, low voltage wires for the outside irrigation system were zip tied on to and supported by the fire sprinkler pipes. This was verified by the executive director. 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. The first floor mechanical room with natural gas fired furnace units had 10 conduit penetrations that were not fire stopped between the conduit and the drywall. This was verified by the executive director.The first floor mechanical room with the natural gas fired furnace units had a hole under the ductwork above the entry door to the room with low voltage cables passing through that was not fire stopped. This was verified by the executive director. 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: Observed in Building Tour. The fire sprinkler head in the kitchen was laden with dust and debris. This was verified by the executive director. 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. In the basement electrical room, a large bundle of low voltage wires was zip tied to the fire sprinkler system hanger. This was verified by the executive director. 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:

Observed in Document Review. The annual fire alarm system testing report did not include the NFPA standard(s) referenced for the activity. This was verified by the executive director.The annual fire extinguisher inspection report did not exist. This was verified by the executive director.

Observed in Record Review. In 11 of 13 patient records reviewed, the written plan of care was not based on the patient’s goals and the time frames, settings, and services required to meet those goals. For example, in the chart for HV#1, in the patient goal for pain management, the time frame for goal achievement was the last day of the current benefit period. Pain will be managed as evidenced by pt will report pain level at 2 or less using 0-10 scale or by observation using FLACC scale for pain rating. In the chart for HV#2, there were no goals on the POC related to the problem of the patient's picking at his skin for which the RN had provided fidget toys and sleeves in an effort to distract the patient and prevent injury as discussed during the visit. In the chart for RR#2, there were no goals for the safety issues of oxygen use and fall risk on the POC. There was no goal related to the problem of infrequent passage of stool on the POC. In the chart for RR#3, the goal target dates for palliative/safety goals were not appropriate as they were the last day of the benefit period, “Patient/caregiver will verbalize understanding of falls/injury prevention and home safety measures” and “Patient will be pain free or verbalize an acceptable pain level with current pain management regimen”. In the chart for RR#4, the goal was not measurable, “Maintenance of respiratory baselines as evidenced by breathing at optimal level within disease parameters.” In the chart for RR#5, the goal target dates for safety goals were not appropriate Patient /caregiver will verbalize understanding of falls/injury prevention and home safety measures with target date the end of the benefit period. The same issue appeared in the chart for RR#6. In the charts for RR#7, RR#9 key safety goals did not have an appropriate time frame Patient/ caregiver can identify potential complications; actions to take; when to call Hospice; Target Date: last day of BP. RR#9 goal - the patient to have knowledge of safety awareness was not individualized to this patient with dementia, exhibiting moderately impaired short and long-term memory nor was the timeframe of the end of the benefit period appropriate. There was no goal related to the G-tube site. In the chart for RR#10, all goals were the last date of the BP and not individualized to the patient’s needs. This was discussed with the Clinical Director and Executive Director.

Observed in Record Review. In 11 of 13 patient records reviewed, the plan of care (POC) did not include all services needed for the palliation and management of the terminal illness and related conditions, and did not include the following: Medications and treatment necessary to meet the patient’s needs. In the chart for HV#1, the patient had oxygen in the residence, yet the POC did not include any safety interventions related to oxygen use. Organizational policy, Oxygen and Fire safety in the Home required these interventions to be present in the patient care plan. During HV#2, it was observed by and discussed with the RN who has provided fidget toys and sleeves to protect patient's skin due to his history of picking at his skin and causing open areas. This problem and associated interventions were not added to the POC. In the chart for HV#3, in the first SN visit of the benefit period, the RN noted that the patient was not needing the Norco for pain and was using Tylenol BID for pain instead. This was not on the POC. In the charts for HV#3, RR#2, RR#4, the patients are on oxygen, yet there are no interventions related to oxygen safety on their POC. In the chart for RR#2 the patient would like to eat, is hungry, with moderate nutritional risk however there were interventions related to this palliative problem on the plan of care. The patient was using Boost and/or Ensure as nutritional supplement according to the SN notes, yet these were not on the POC. The patient had a problem with “infrequent passage of stool” identified in the SN assessment, yet no interventions other than medications. Additionally, the patient had a healing surgical wound with drainage upon admission yet there were no interventions on POC. The patient developed a pressure ulcer for which the RN documented an Optifoam was applied. No order was found for this treatment. In the chart for RR#3, the patient was assessed to be at risk of skin breakdown, yet no interventions were on the POC; at risk of falls, yet no interventions other than assessment of risk were on the POC. In the chart for RR#4, the patient was on bi-pap, yet this was not on the POC, there were no bi-pap settings on the POC. In the chart for RR#5, the Volunteer saw the patient multiple times during the last week of life. This was not on the POC. Additionally the patient was ordered both Morphine and Acetaminophen prn for pain without further clarification about parameters for administration of which medication. In the chart for RR#7, the patient had a pressure ulcer upon admission. The POC had no interventions/goals related to this. Additionally, the day after admission, orders were received for Plurex drainage with dressing change by the RN every other day. The detail of the dressing change were not included in the order and the POC was not updated with any interventions/goals related to this problem. In the chart for RR#8, there are 4 prn medications for constipation and 3 prn pain medications without clarification when to give which medication. Additionally, the POC for the most recently completed benefit period was not updated to remove orders for a wound which was no longer present. In the chart for RR#9, the patient had a g-tube for feedings. The POC did not include any interventions related to care of the g-tube site. In the chart for RR#10, there were no orders for wound care provided by the RN on visit number 2; no interventions related to the patient’s high risk of pressure ulcer development. This was discussed with the Clinical Director and Executive Director.

Observed in Record Review. In 7 of 13 patient records reviewed, the plan of care (POC) revisions did not address the patient’s progress toward goals and outcomes. In the charts for HV#1, HV#2, HV#3, RR#7, RR#8, RR#9, RR#10 the IDT documentation did not address progress toward goals in the current or immediate past benefit periods. Anticipated target dates had simply been moved forward to the last day of each benefit period. An example in the chart for HV#2 included patient/caregiver will verbalize understanding of falls/injury prevention and home safety measures which began with the patient's admission, more than 9 months prior to the survey. This was discussed with the Clinical Director and Executive Director.

Observed in Record Review. In 3 of 13 patient records reviewed, the organization had not provided the patient with care, treatment, or services according to the patient's individualized plan of care. In the chart for HV#2, during week 3 of the current benefit period (BP), the aide was ordered 4-5 times/week, yet only 3 visits were made with no indication why visits were missed. In the chart for RR#4, in the final BP, the aide was ordered 2-3w1, 4-5w11, but did not perform any visits in week one of the BP. In the chart for HV#1, Volunteer services were added by an administrative staff person after the beginning of the current benefit period, however there was no documentation in the record to indicate that the IDT discussed and approved this change. The MSW note indicated only that the Caregivers were now open to adding Volunteer services for companionship. This was discussed with the Clinical Director and Executive Director.

Observed in Record Review. In 2 of 2 patient records reviewed, the hospice had not developed a bereavement plan of care that specified the type of bereavement services to be offered and the frequency of service delivery. In the charts for BR#1 and BR#2, the plans of care did not include the planned routine mailings as described by the Bereavement Counselor.

Observed in Tracer Activities. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews:  §418.56.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization had not managed safety and security risks. During HV#2, the caregiver indicated to this surveyor and the RN that the oxygen concentrator and extra tanks were stored in a small, closed coat closet in the living room of the residence. The RN did not recognize the danger of this practice during the visit and did not provide education to the caregiver about the practice. This was discussed with the Clinical Director and Executive Director.