Every finding on record at Hospice of the Foothills

Observed in Tracer Visit. In 8 out of 19 records reviewed, multiple PRN medications were prescribed to treat the same symptom without clear guidance on when each medication should be administered. Specifically, in RRHV#1, both Lorazepam and Seroquel were ordered PRN for agitation. In RRHV#2, Tylenol and Morphine were ordered PRN for pain. Senna, Dulcolax suppositories, and enemas were ordered PRN for constipation. In RRHV#3, Tramadol, Morphine Sulfate, Diclofenac Sodium ER, and Tylenol were prescribed PRN for pain. In RRNHV#5, Lorazepam and Haldol were prescribed PRN for both moderate and severe agitation. In RRNHV#6, Tylenol and oxycodone were ordered PRN for pain. In RRNHV#7 Tylenol and Morphine Sulfate was ordered PRN for pain. In RRNHV#9, Tylenol and Morphine sulfate were ordered PRN for pain. In RRDC#1, Morphine, Tylenol, and Ibuprofen was prescribed for pain. In each instance, there was no clarification differentiating when to use each medication. These findings were confirmed by the DCPS and the Clinical Manager.

Observed in Record Review. In 2 out of 19 records, the organization did not provide the patient with care, treatment, or services according to the patient's individualized plan of care. Examples: In RRNHV#5 benefit period 2, 1 nursing visit was missed during week 1 and 1 aide visit was missed in week 2. In RRNHV#7, 2 aide visits were missed in weeks 1 and 2 of benefit period 1. These findings were validated by the DPCS and were not known prior to the survey.

Observed in Record Review. In 1 of the 3 bereavement records reviewed, bereavement services did not adequately reflect the needs of the bereaved. For example, during the surveyor's review of RRBR#1 with the Bereavement Coordinator, the Coordinator verbalized that the bereaved individual’s risk level changed from low risk at the initial post-death bereavement assessment to high risk within a couple of months of the patient’s death. However, the bereavement record did not reflect an updated risk level or corresponding interventions per policy to address the increased needs of the bereaved. The Bereavement Coordinator agreed with the finding.

Observed in Record Review. The organization was unable to provide documentation of defined competencies for the roles of Volunteer Coordinator and Bereavement Coordinator. This was confirmed by the HR Director. Observed in Record Review. In 2 out of 9 HR records reviewed, competencies were not assessed or documented as part of staff orientation. Example: In HR#3 (Volunteer Coordinator) and HR#8 (Bereavement Coordinator) files, no competencies had been documented since the date of hire. This finding was confirmed by the HR Director.

Observed in Record Review. For selected clinicians, clinical documentation was not properly authenticated with required titles. Specifically, in RRHV#1, the electronic signatures on clinical notes for 2 of 3 nurses and 1 spiritual counselor did not include the clinician’s title or a secure unique identifier. In RRHV#2, the electronic signatures for 3 nurses likewise lacked a title or secure unique identifier. This finding was confirmed by the DCPS.

Observed in Record Review. In 2 out of 2 live discharge records, the hospice did not provide a discharge summary to the patient's physician or other licensed practitioner in accordance with law and regulation. Examples: In RRDC#1 and RRDC#2, there was no evidence in the record of the discharge summary being sent to the patient's physician or other licensed practitioner after discharge. This was confirmed by the DCPS.

Observed in Tracer Activities. the organization failed to provide emergency preparedness training to volunteers. During tracer activities for Emergency Management, the hospice nurse surveyor observed the Volunteer Training Manual did not include emergency management. And after discussion with the Volunteer Coordinator, it was noted that education on the organization's emergency management plan was not currently being offered to the Volunteers. This was discussed and reviewed with the Executive Director.

Observed in Record Review. In 3 of 3 patient records reviewed, the organization failed to reassess its patient according to policy. During record review for HV#2, RR#3 and RR#10, the hospice nurse surveyor observed the organization did not follow their policies for reassessment. For example in HV#2, the hospice nurse surveyor observed the patient had a fall on 3/21 and the triage nurse assessed over the phone with the facility. In RR#10, the triage nurse received a phone call on 1/21 about a patient fall and it was assessed over the phone with the facility. At a visit a few days later the nurse noted bruising from the fall. The organizational fall policy states that a visit would be required. In RR#3, the hospice nurse surveyor observed the patient had moved to a new location and during the tuck in visit the nurse was advised the patient came with a large rash to her buttocks. There was no documentation of the rash per the organization's policy Comprehensive Assessment- Updates. This was discussed and reviewed with the Executive Director.

Observed in Record Review. In 13 of 13 patient records reviewed, the organization failed to plan the patient's care. During record review for all records, the hospice nurse surveyor observed timeframes were not measurable or individualized. For example in HV#1, pt coping with anxiety will be effective next 60 days but that goal and timeframe had carried over certification after certification with no update. This was discussed and reviewed with the Executive Director.

Observed in Record Review. In 3 of 3 patient records reviewed, the organization failed to plan the patient's care. During record review for BR#1, BR#2, and BR#3, the hospice nurse surveyor observed the Bereavement care plans did not include specific, individualized interventions, and the timing and frequency of activities were not included in the POC. Per conversation with the Bereavement Coordinator, the mailing and outreach activities were the same for all risk levels. This was discussed and reviewed with the Executive Director.

Observed in Record Review. In 2 of 2 patient records reviewed, the organization failed to plan the patient's care. During record review for HV#1 and HV#2 ( 2/2 receiving aide services), the hospice nurse surveyor observed the organization failed to include fall risk precautions on the aide care plan. After discussion with the Manager, it was noted the organization put the precautions onto the face sheet but it was not their practice to include in on the aide care plan. The organization put a plan in place to remedy this item during survey. This was discussed and reviewed with the Executive Director.

Observed in Record Review. In 1 of 13 patient records reviewed, the organization failed to maintain an accurate record to reflect the patient's care, treatment or service. During HV#1, the hospice nurse surveyor observed the notes on 3/14 and 3/16 stated she would be following up by telephone with daughter the next day. There was no documentation of the follow up. After discussion with the team, the hospice nurse surveyor noted the phone calls were made as evidenced by the nurses phone contacts but there was no documentation in the medical record. The nurse did place a late entry during survey. This was discussed and reviewed with the Executive Director.