Every finding on record at Hospice of Marion County, Inc.

Observed in Record Review. During RRNHV# 1, RRNHV# 2, RRNHV# 3, RRNHV# 4, RRNHV# 5, RRNHV# 6, RRNHV# 12, RRNHV# 13, AND RRNHV3 14's patient recordS review it was noted the organization had not ensured the written plan of care was based on the patient's goals and the time frames required to meet those goals. For example: review of RRNHV# 1's plan of care revealed the goal Seizure activity will be minimized patient will have no increase in seizure activity for 2 weeks. However, there was no indication how to measure no increase. Review of RRNHV# 2, RRNHV# 3, and RRNHV# 6's plans of care revealed the Chaplain goal, Patient/Caregiver/Family will express appropriate feelings of hope, peace, and contentment. However, there were no indication on how to measure appropriate or a time frame. Review of RRNHV# 4’s plan of care revealed RRNHV# 4’s had a stage 1 pressure ulcer to the left heel. Further review of the plan of care revealed the goal, optimal skin integrity maintained with no indication what optimal was and no time frame. Review of RRNHV# 5’s plan of care revealed the goal, Patient/Caregiver/Family receives appropriate emotional support. However, there was no indication of what was appropriate and no time frame. Review of RRNHV# 12, RRNHV# 13, and RRNHV# 14's plans of care revealed multiple unmeasurable goals with no frames. This was reviewed, discussed, and validated with the Corporate Compliance Director. Observed in Record Review. In 12 of 31 patient records reviewed, The surveyor observed that the goals for pain did not reflect patients goal for pain control and simply had a vague statement which stated pain to be controlled to acceptable level and in all three records the patients had pain identified as issue and were on pain medication. Further goals for patients with actual skin issues to include decubitus ulcers and skin tears stated as goal: no further skin breakdown. Lastly surveyor noted on 5/6 records that goals for chaplain had been vague to include stated goal of : family express appropriate feelings of hope and peace and contentment .

Observed in Record Review. In 15 of 31 patient records reviewed, the surveyor observed that the order frequency for chaplains had contained stand alone only PRN visits. This issue was discussed with organization clinical supervisor and confirmed. Observed in Record Review. During RRNHV# 1, RRNHV# 2, RRNHV# 3, RRNHV# 4, RRNHV# 5, RRNHV# 7, RRNHV# 8, RRNHV# 9, RRNHV# 10, and RRNHV# 12's patient records revealed that the order frequency for chaplains as needed (PRN) visits only with no assessed need. This issue was reviewed, discussed, and validated with Corporate Compliance Director.

Observed in Infection Control Tracer. Upon interview, the pharmacist confirmed that the organization had not been using one of the manufacturer approved disinfectants to clean the IV pumps. Observed in Pharmacy. The pharmacy technician confirmed that the three hand sanitizer bottles for use by staff in the pharmacy had an expiration date of 3/2022.

Observed in Patient Home. In 3 of 6 home visits conducted, the surveyor observed that the organization had not provided a copy of the hospice written policies and procedures on the management and disposal of controlled drugs to the patient or patient representative and family. This issue was both observed by and confirmed by organization supervisor on visit with surveyor.

Observed in Building Tour. In 1 of 3 IPU Medication Room Observations, During IPU# 1's medication room observation it was noted the organization had not ensured staff followed the organization policy IDT 0202, that included all narcotics will be counted, logged and signed every shift by two licensed nurses and witnessed on the narcotic records. For example: During the medication room observation multiple expired controlled medications were found on the top shelf of the locked narcotic medication cabinet. Review of the controlled medications narcotic count sheets revealed no documentation of the expired controlled medication located on the top shelf. The registered nurse shared that the pharmacist comes once a month and destroys the expired controlled medications with the IPU (Inpatient Unit) Manager and nursing staff did not count the expired controlled medications once they are on the top shelf. This was reviewed, discussed, and validated with the Director of the Inpatient Units.

Observed in Pharmacy. Upon interview, the pharmacist confirmed that the organization had not been performing a volumetric test of the IV pump between patients. Observed in Tracer Activities. Upon interview, the pharmacist confirmed that the organization had not been performing the annual preventative maintenance on the IV pumps as required by the manufacturer. The service manual was not available. Observed in Tracer Activities. Upon interview, the pharmacist confirmed that the organization had not been performing basic safety, operation and function checks on the IV pumps between patients.

Observed in HR File Review. In 2 of 4 HR files reviewed for Inpatient Unit, During HR# 1 and HR# 3's HR files review it was noted the organization had not ensured the Inpatient Unit staff received restraint and seclusion education. This was reviewed, discussed, and validated with the Corporate Compliance Officer.