Every finding on record at Hospice of Northwest Ohio

Observed in Record Review. In 1 of 3 patient records reviewed, bereavement records, the organization failed to assess its patient's. During record review for HOSRRBR#2, the Hospice Nurse Surveyor observed the initial bereavement assessment was completed on the patient's daughter. But after death the bereavement activities and primary bereaved was done on the son. The son did not have a documented bereavement assessment in the EMR. This was discussed and reviewed with the Hospice Leadership Team. Observed in Record Review. In 1 of 19 patient records reviewed, the organization failed to assess patient's needs. During record review for HOSRRNHV#9, the Hospice Nurse Surveyor observed the initial bereavement assessment was not completed. Upon review, the assessment stated low risk, the boxes were not checked and there was no name of the bereaved present. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Record Review. In 2 of 19 patient records reviewed, the organization failed to maintain a complete and accurate record. During record review for HOSRRNHV#4 and HOSRRNHV#9, the Hospice Nurse Surveyor observed the documentation was conflicting. For example in HOSRRNHV#4, the patient had no Michigan DNR in his documentation but he did have a goal of completing Michigan DNR that showed in progress. His aide care plan stated Michigan DNR in place. And the overall Plan of Care stated Full Code. IDG notes from most recent IDG stated DNR in place. Upon discussion with the Team Lead, she stated she had reached out to the RN who states the family is still working on the Michigan DNR form. The patient chart did have an Ohio DNR in place for the respite and IPU visit he had. In HOSRRNHV#9, the Code status had recently changed but the aide plan of care still showed Full Code. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Record Review. In 1 of 19 patient records reviewed, the organization failed to provide interdisciplinary, collaborative care, treatment, or services. During the home visit and record review for HOSRRHV#3, the Hospice Nurse Surveyor observed aide services was needed but there was no documentation of the collaboration. During the visit the RN asked the daughter how the aide services were going that had been ordered 5 days prior. The daughter stated that the aide services had not begun. Upon record review, it was noted the RN had put an aide care plan in 5 days previous but there was no documentation to the provider, the IDG or the office staff who coordinate the services that aide services were needed. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Record Review. In 1 of 19 patient records reviewed, the organization failed to assess and reassess its patients. During record review for HOSRRNHV#2, the Hospice Nurse Surveyor observed the spiritual counselor called the day after start of care to schedule the comprehensive assessment and left a voice mail. There was no further contact or documentation about outreach until the comprehensive was documented 7 days later, making the assessment completed on day 8. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Patient Home. In 1 of 2 home visits conducted, where a medication reconciliation was completed, the organization failed to maintain an accurate record. During the home visit for HOSRRHV#1, the Hospice Nurse Surveyor observed the patient medication list and the medications she was taking did not match. For example in HOSRRHV#`1, the patient was not currently taking her Omeprazole but it had not been discontinued. She was taking a multi-vitamin and Vitamin B-12 but they were not on the medication list. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Record Review. In 2 of 3 patient records reviewed, the organization failed to authenticate the patient record. During record review for HOSBR#2 and HOSBR#3, the Hospice Nurse Surveyor observed the patient's bereavement activity list, which takes the place of the bereavement care plan, was not dated or signed. This was discussed and reviewed with the Hospice Leadership Team.

Observed in Patient Home. In 1 of 1 home visits conducted, where oxygen was present, the organization failed to provide patient education and training based on each patient's needs and abilities. During the home visit for HOSRRHV#1, the Hospice Nurse Surveyor observed the staff did not provide education on the safe storage of oxygen cylinders in the home. The patient had 4 oxygen tanks standing up, unsecured, next to the television. This was discussed and reviewed with the Hospice Leadership Team.

Observed in HR File Review. In 1 of 11 HR files reviewed, the organization did not provide initial emergency preparedness training. In HR #10, the surveyor noted the volunteer did not receive initial training as part of their orientation. This was confirmed with the Volunteer Coordinator.

Observed in Record Review. In 3 of 13 patient records reviewed, the hospice did not conduct and document in writing a patient-specific comprehensive assessment and reassessment. In RR #1, the surveyor noted the patient was identified as having 1+ pitting edema on admission; however, there was no reassessment of the edema at subsequent nursing visits. This was confirmed with the Compliance Coordinator. In RR #2, the surveyor noted the skilled nurse documented the patient's toe nail had fallen off and a bandaid was applied to site; however, there was no further reassessment of the toe performed. In addition, the patient developed a pressure ulcer second week of service to the coccyx; however, the assessment did not include staging of the pressure ulcer; however, the organization's wound assessment procedure from Lippincott required use of a staging or classification system. This was confirmed with the Compliance Coordinator. In RR #3, the surveyor noted the skilled nurse did not assess the patient's port site on the admission comprehensive assessment. This was confirmed with the Compliance Coordinator.

Observed in Record Review. In 1 of 13 patient records reviewed, the hospice interdisciplinary group did not complete the comprehensive assessment no later than 5 calendar days after the election of hospice. In HV #1, the surveyor noted the spiritual assessment did not occur until the 6th day after the election of the hospice benefit. This was confirmed with the Compliance Coordinator.

Observed in Record Review. In 1 of 13 patient records reviewed, the comprehensive assessment did not include an initial bereavement risk assessment. In RR #2, the surveyor noted the comprehensive assessment upon admission did not include a bereavement risk assessment. This was confirmed with the Compliance Coordinator.

Observed in Record Review. In 1 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. In RR #1, the surveyor noted the plan of care included the following goal patient will meet their verbal pain rating of 3 or less 75% within the next two weeks; however, the patient's pain level was 10 on admission. In addition, the plan of care included a non-measurable goal: State patient's priority focus: Michigan DNR, remain at home, support for daughter, symptom management. The goal also did not include a time frame. This was confirmed with the Compliance Coordinator.

Observed in Record Review. In 9 of 13 patient records reviewed, the plan of care did not include interventions to manage pain and symptoms. In HV #1, the surveyor noted the patient was identified as having diarrhea on admission assessment; however, the plan of care did not include interventions to address this identified need. This was confirmed with the Compliance Coordinator. In HV #2, the surveyor noted the patient was identified as having dizziness, anxiety and swallowing difficulties; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the Compliance Coordinator. In RR #1, the surveyor noted the patient was identified as having constipation, edema, fall risk, and skin breakdown; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the Compliance Coordinator. In RR #2, the surveyor noted the patient was identified at risk for skin breakdown; however, the plan of care did not include interventions to address this identified need. This was confirmed with the Compliance Coordinator. In RR #3, the surveyor noted the patient was identified as having sleep difficulty and anxiety; however, the plan of care did not include interventions to address these identified needs. The plan of care was updated 15 days after the start of care to address anxiety. This was confirmed with the Compliance Coordinator. In RR #4, the surveyor noted the patient was identified as having chest pain and fatigue; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the Compliance Coordinator. In RR #5, the surveyor noted the patient was identified as having anxiety, agitation, and hallucinations; however, the plan of care did not include interventions to address these identified needs. This was confirmed with the Compliance Coordinator. In RR #6, the surveyor noted the patient was identified as having shortness of breath and at risk for skin breakdown; however, the plan of care did not include interventions to address these identified needs. In addition, the patient developed nausea the second week of service; however, the plan of care was not updated to include this symptom. This was confirmed with the Compliance Coordinator. In RR #7, the surveyor noted the patient was identified as having anxiety and edema; however, this plan of care did not include interventions to address these identified needs. This was confirmed with the Compliance Coordinator.

Observed in Record Review. In 3 of 13 patient records reviewed, the plan of care did not include a detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs. In HV #2, the surveyor noted the hospice performs a skilled nursing initial visit and the next day performs a follow-up visit; however, the plan of care visit frequency for skilled nursing was only one time per week for the first week. This was confirmed with the Compliance Coordinator. In HV #3, the surveyor noted the plan of care did not include phone visits; however, the chaplain performed the spiritual assessment by phone. This was confirmed with the Compliance Coordinator. In RR #8, the surveyor noted the visit frequency for massage therapy indicated 4 prn visits; however, there was no actual visit frequency planned. This was confirmed with the Compliance Coordinator.

Observed in Record Review. In 10 of 13 patient records reviewed, the plan of care did not include drugs and treatment necessary to meet the needs of the patient. In HV #1, the surveyor noted the plan of care medication orders included lamotrigline 25 mg one tab daily and a second entry of lamotrigine 25 mg 2 tabs daily; however, the actual dose was one tab in am two tabs in pm. In addition, the medication order for senna 8.6 mg 1 - 4 tabs prn constipation; however, the order did not specify when to take one tablet versus four. There were two prn constipation orders, senna and Dulcolax; however, the order did not specify which medication to take first. Also, in the second month of service, the skilled nurse started filling a med box for the patient; however, the plan of care was not updated to include this intervention. This was confirmed with the Vice President of Quality and Compliance. In HV #2 and RR #5, the surveyor noted the plan of care included the following medication order: dilaudid 2 mg as needed take as directed for moderate to severe pain/shortness of breath if ineffective may repeat same dose x 1; however, the order did not specify frequency of administration. This was confirmed with the Vice President of Quality and Compliance. In HV #3, the surveyor noted the plan of care did not include safety measures and diet. In addition, the patient had an ostomy; however, the plan of care did not include interventions to address this identified need. This was confirmed with the Compliance Coordinator. In RR #1and RR #4, the surveyor noted the patient had an AICD device; however, the plan of care did not include interventions related to this device. This was confirmed with the Compliance Coordinator. In RR #2, the surveyor noted the plan of care included Dulcolax and enema prn for constipation; however, there was no indication as to when to give which med. In addition, the plan of care included an order for Insulin lispro 1- 5 units four times daily; however, the order did not specify when to give 1 unit versus 5 units. Also, the wound care order the fourth day of service included prn; however, there was no indication given. This was confirmed with the Compliance Coordinator. In RR #3 and RR #4, the surveyor noted the plan of care medication order included senna 8.6 mg 1 - 4 tabs prn constipation; however, the order did not specify when to take one tablet versus four. This was confirmed with the Compliance Coordinator. In RR #7, the surveyor noted the patient had a surgical wound to sternum on admission with wound care being provided by the wife; however, the plan of care did not include wound care interventions. This was confirmed with the Compliance Coordinator. In RR #8, the surveyor noted the plan of care included massage therapy; however, the plan of care did not include location, duration, type of massage. This was confirmed with the Compliance Coordinator.

Observed in Record Review. In 3 of 13 patient records reviewed, the plan of care did not include medical supplies and appliances necessary to meet the needs of the patient. In HV #1, RR #4 and RR #8, the surveyor noted the plan of care did not include the durable medical equipment/supplies necessary to meet the patient's identified needs as evidenced by this section was blank on the plan of care. This was confirmed with the Compliance Coordinator.

Observed in Record Review. In 3 of 13 patient records reviewed, the hospice did not document the discussion of the interdisciplinary meeting. In HV #1 and RR #3, the surveyor noted all IDG meeting documentation indicated this patient's plan of care was reviewed, and, if needed, revised by core members of the IDG including at least one physician, one registered nurse, one social worker, one other counselor and other members of the IDG who attended this team meeting. Signature log of attendees is available through Health Information Management. Physician reviewed medications. IDG reviewed plan of care summaries and visit orders from last 1 - 2 weeks. There was no documentation as to what was discussed regarding the patient. This was confirmed with the Compliance Coordinator. In RR #2, the surveyor noted the meeting documentation from the first meeting did not include what was discussed at the meeting. This was confirmed with the Compliance Coordinator.

Observed in Record Review. In 1 of 13 patient records reviewed, the organization did not provide the patient with care, treatment or services according to the patient's individualized plan of care. In RR #2, the surveyor noted the MSW visit frequency on the plan of care was two times per month; however, three MSW visits made the first month of service. In addition, the plan of care SN visit frequency was 1 week 13; however, three visits were made the first week of service, two visits made the second week of service. The second visit the second week of service was noted to be prn; however, the order for prn visits was for symptom management and this visit was a care planning meeting with the family. This was confirmed with the Compliance Coordinator.

Observed in Record Review. In 1 of 13 patient records reviewed, all disciplines that provided care did not collaborate in the care of the patient and coordinate their efforts to support the goals outlined in the plan of care. In RR #3, the surveyor noted the skilled nurse documented the port was not able to be flushed; however, there was no documentation the physician was notified. This was confirmed with the Compliance Coordinator.

Observed in Individual Tracer. In 1 of 3 home visits conducted, the organization did not use standard precautions to reduce the risk of infection. In HV #2, the surveyor noted the skilled nurse failed to perform hand hygiene consistent with policy. For example, the nurse touched the patient and then went into their bag without performing hand hygiene. This was confirmed with the Vice President of Quality and Compliance. Observed in Individual Tracer. In 1 of 3 home visits conducted, the organization did not implement infection prevention and control activities when cleaning and performing disinfection of medical supplies and devices. In HV #2, the surveyor noted the skilled nurse returned the blood pressure cuff, stethoscope and pulse oximeter to their bag without cleaning the equipment as required by the organization policy. This was confirmed with the Vice President of Quality and Compliance.

Observed in Record Review. In 5 of 5 patient records reviewed where the patient received aide services, a registered nurse did not prepare written patient care instructions for the hospice aide. In HV #1 and HV #2, the surveyor noted the aide plan of did not include fall precautions and bleeding precautions. This was confirmed with the Compliance Coordinator. In HV #3, the surveyor noted the aide plan of care did not include swallowing precautions. In addition, the aide plan of care was not updated to remove hair care and shampoo as the aide reported the patient refused to allow her to perform hair care/shampoo. This was confirmed with the Compliance Coordinator. In RR #2 and RR #8, the surveyor noted the aide plan of care indicated apply barrier cream as directed; however, there were no instructions provided on the aide plan of care. This was confirmed with the Compliance Coordinator.

Observed in Record Review. In 1 of 5 patient records reviewed where the patient received aide services, the hospice aide did not provide services that were ordered in the plan of care.In HV #3, the surveyor noted the aide reported to surveyor she prepared snacks for the patient. In addition, the aide documented she prepared lunch for the patient; however, food preparation was not assigned on the aide plan of care. This was confirmed with the Compliance Coordinator.

Observed in Record Review. In 2 of 5 patient records reviewed where the patient received aide services, the registered nurse did not supervise the hospice aide during an on-site visit no less frequently than every 14 days.In HV #3, the surveyor noted the aide supervisory visit was completed at 16 days and then did not address whether the aide was following the plan of care. This was confirmed with the Compliance Coordinator.In RR #2, the surveyor noted the aide supervisory visit was incomplete and did not include whether the aide was following the plan of care. This was confirmed with the Compliance Coordinator.

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:  - §418.100 and 418.104, 418.56.

Observed in HR File Review. In 1 of 11 HR files reviewed, the hospice did not assess competence as part of orientation. In HR #2, the surveyor noted initial competence of the volunteer coordinator was not assessed as part of their orientation. This was confirmed with the HR Coordinator.

Observed in Record Review. In 1 of 13 patient records reviewed, the patient record did not contain all clinical information. In RR #2, the surveyor noted the Vitamin B12 administered this month by the skilled nurse did not specify the dosage or the route of administration. This was confirmed with the Compliance Coordinator.

Observed in Record Review. In 13 of 13 patient records reviewed, all entries in the patient record were not appropriately authenticated. In all records reviewed, the surveyor noted the admission assessment and routine skilled nursing visit notes were not electronically signed by the clinician. In addition, the admission assessment for the medical social worker and spiritual counselor were not electronically signed. In discussion with the leadership, the electronic medical record vendor had disabled the electronic signature. This was confirmed with the Compliance Coordinator.

Observed in Record Review. In 1 of 3 closed records reviewed, In RR #8, the surveyor noted the discharge summary only indicated the patient moved from the service area; it was not a summary of the services provided. This was confirmed with the Compliance Coordinator.

Observed in Record Review. In 1 of 13 patient records reviewed, the patient did not educate the patient on an individualized emergency plan. In HV #3, the surveyor noted the individualized emergency plan in the patient's home was blank. In addition, the plan in the medical record did not include the patient's procedures to follow if care, treatment or services were disrupted by natural disaster or emergency.

Observed in Record Review. In 1 of 2 patient records reviewed where the patient resided in a nursing facility, the hospice plan of care did not identify which provider was responsible for performing the respective functions in the hospice plan of care. In RR #2, the surveyor noted the patient was diabetic and on insulin; however, the plan of care did not specify the facility nurse was to monitor the blood sugar and the frequency of that monitoring until 16 days after start of care. In addition, the wound care order did not specify which provider was to perform this task. This was confirmed with the Compliance Coordinator.