Every finding on record at Hospice of North Central Oklahoma, Inc.

Observed in Document Review. it was learned that the organization did not provide ongoing education and training to all staff and volunteers consistent with their roles and responsibilities in an emergency at least every two years. This was confirmed in the HR competence session and reviewed, discussed, and validated with the CEO, CCO and CBO.

Observed in Record Review. In 18 of 19 patient records reviewed, interdisciplinary notes did not document patient decline, changes, and progress towards goals since the previous reassessment. In addition, there were no documented plans for the following two weeks. This RFI was reviewed, discussed, and validated with the CEO, CCO and CBO.

Observed in Record Review. In 19 of 19 patient records reviewed, the organization did not plan the patient’s care based on goals that were specific, individualized, and included time frames for completion. For example: Patient will achieve and maintain optimal physical comfort; Facilitate normal grief process; patient will achieve and maintain optimal skin integrity as disease progression allows; patient will achieve and maintain regular bowel elimination and skin integrity; patient will achieve optimal breathing patterns, airway patency and comfort. This RFI was reviewed, discussed, and validated with the CEO, CCO and CBO.

Observed in Patient Home. In 2 of 2 home visits conducted, where equipment was used and cleaned, the organization did not implement its infection prevention and control activities. For example, during HV #3 and HV #4 the surveyor observed that nurses used Saniwipes but did not follow the manufacturer's guidelines for use requiring dwell time of two minutes. This RFI was reviewed, discussed, and validated with the CEO, CCO and CBO. Observed in Patient Home. In 1 of 4 home visits conducted, the organization did not implement the infection prevention and control activities it had planned. During HV #4 the LPN applied hand sanitizer gel but did not continue to rub her hands until dry. Rather, she waved her hands in the air to accelerate drying. Her actions did not comply with policy and accepted standards of practice. This RFI was reviewed, discussed, and validated with the CEO, CCO and CBO.

Observed in Tracer Activities. In 2 of 2 HR files reviewed, competence was not assessed and documented for volunteers as part of the orientation process. This was learned during the volunteer services tracer and validated in the competence assessment tracer. This RFI was reviewed, discussed, and validated with the CEO, CCO and CBO.

Observed in Record Review. In 10 of 19 patient records reviewed, the certificate of terminal illness (CTI) did not support a patient’s life expectancy of six months or less if the illness was to run its normal course, nor did it comply with policy PC-110 entitled Certification of Terminal Illness. Additionally, documentation was the same on some CTIs where patients were recertified. Finally, documentation did not reflect patient decline to support the on-going appropriateness for the hospice benefit. This was found in the records of HV#1, HV#2, HV#3, HV#4, NHV#1, NHV#2, NHV#3 NHV#4, NHV#5, NHV#6, NHV#10 This RFI was reviewed, discussed, and validated with the CEO, CCO and CBO.

Observed in Patient Home. In 2 of 2 home visits conducted, where medications were reconciled, the clinician failed to conduct an effective assessment. At HV #3 the RN did not complete medication reconciliation as required by policy. And at HV #4 the LVN stated that her medication reconciliation consisted of comparing the hospice list to the MAR in the SNF. She did not collaborate with facility staff to compare bottle or blister pack labels to paper documents. This RFI was reviewed, discussed, and validated with the CEO, CCO and CBO.

Observed in Patient Home. In 1 of 2 home visits conducted, where patients were receiving oxygen therapy, the hospice did not identify and manage potential safety and security risks in the home. For example, at HV #3 it was observed that one of two full M-24 cylinders was standing unsecured. Two empty M-4 cylinders were standing unsecured as well. The RN did not independently recognize the safety concern and take appropriate action. This RFI was reviewed, discussed, and validated with the CEO, CCO and CBO.