Every finding on record at Hospice of the North Coast

Observed in Record Review. In 1 of 20 active patient records reviewed, the organization failed to conduct and document a patient specific comprehensive assessment and reassessment. In record RRNHV#1 there was no initial bereavement assessment documented. This RFI was reviewed with the Executive Director, Director of Patient Care Services, and Chief Financial Officer.

Observed in Record Review. In 18 of 18 active home patient records reviewed, most of plan of care goals were not measurable. Here are some examples. Patient/family will have spiritual needs met; IDT will develop a plan to promote patient comfort and assist in the achievement of a comfortable peaceful death; promote IDT will provide safe and personal care and hygiene; IDT will promote skin integrity; IDT will maintain clean, safe environment; patient's personal care needs will be met; patient will demonstrate ability to cope with limitations; patient/caregiver will verbalize relief from anxiety; patient recognizes energy limitations and understands/uses energy conservation techniques; patient/caregiver will demonstrate necessary behaviors to maintain good safety awareness and minimize the risk of falls and/injury. Additionally, completion target dates were 10 months after their creation. This RFI was reviewed with the Executive Director, Director of Patient Care Services, and Chief Financial Officer.

Observed in Patient Home. In 1 of 6 home visits conducted, the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions. At home visit RRHV#4 the Surveyor observed during medication reconciliation that the patient was prescribed Metoprolol Succinate ER 25 mg (generic name) daily, and Toprol-XL ER 200 mg (brand name) daily. There was no documentation in the patient record to indicate that medication duplication was identified and action taken to resolve the problem. This RFI was reviewed with the Executive Director, Director of Patient Care Services, and Chief Financial Officer. Observed in Patient Home. In 1 of 6 patient home visits conducted, the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions, specific to drugs and treatment. At home visit RRHV#3 the Surveyor observed during medication reconciliation that the patient had 5 prn orders for infrequent bowel movements and constipation. These included Senna, Docusate-Senna, MiraLAX, Lactulose, and Bisacodyl suppository. There was no clear direction for the order in which each medication should be used. Despite these five orders, at the time the Surveyor made the home visit, the patient had not had a bowel movement for at least 10 days. This RFI was reviewed with the Executive Director, Director of Patient Care Services, and Chief Financial Officer.

Observed in Record Review. In 18 of 18 active home patient records reviewed, the hospice interdisciplinary team did not consistently update the plan of care. For example, in the meeting notes of core team members there was little or no documentation of patient decline, progress towards desired outcomes, goals and plans for the following two weeks. This RFI was reviewed with the Executive Director, Director of Patient Care Services, and Chief Financial Officer.

Observed in Record Review. In 4 of 20 active patient records reviewed, the organization failed to conduct and document a patient specific comprehensive assessment and reassessment. In record RRNHV#1 there was no initial comprehensive social work assessment documented. In record RRHV#4 there was no initial comprehensive spiritual assessment documented. And in records RRHV#2, RRHV#4, RRHV#5, RRNHV#1, the initial comprehensive spiritual assessment was done by telephone. This RFI was reviewed with the Executive Director, Director of Patient Care Services, and Chief Financial Officer.

Observed in Competency Session. In 1 of 11 HR files reviewed, the organization could not provide documentation of 12 clock hours of education for the home health aide 2023 and 2024 for personnel record HR#6 HHA. This RFI was confirmed by the Director of Patient Care Services.

Observed in Competency Session. In 3 of 11 HR files reviewed, Staff competence was not assessed as required by policy. In personnel files HR#3 MD and HR#4 AMD there was no documentation of competence re-assessment having been completed. The same was found in personnel file HR#11 VOL. This RFI was confirmed by the Director of Patient Care Services.

Observed in Record Review. In 4 of 20 active patient records reviewed, certificates of terminal illness did not include subjective and objective information to support patient life expectancy of six months or less at recertification. For example, in record RRHV#1 the PPS score did not change and there was little subjective documentation to indicate decline in the previous benefit period. In record RRHV#6 13 CTIs, ADLs were consistently 5/6 and the PPS was constant at 40%. There was intermittent documentation of aspiration pneumonia that resolved in the next CTI. The same documentation was found in RRNHV#7 and RRNHV#9. This RFI was reviewed with the Executive Director, Director of Patient Care Services, and Chief Financial Officer.

Observed in Patient Home. In 1 of 6 home visits made, the organization failed to ensure that the patient record contained an accurate medication list. At home visit RRHV#4 the list used during medication reconciliation indicated that the patient was taking Metoprolol Succinate ER 25 mg daily, Toprol-XL ER 200 mg daily, and Nortriptyline. According to the daughter the patient had stopped taking these medications 6 to 12 months prior to the date of the visit. This RFI was reviewed with the Executive Director, Director of Patient Care Services, and Chief Financial Officer.

Observed in Record Review. In 2 of 2 discharge records reviewed, the organization failed to provide the attending physician with a summary. In record RRDC#1 the patient was discharged for extended prognosis. In record RRDC#2 the patient revoked the hospice benefit for aggressive care. This RFI was reviewed with the Executive Director, Director of Patient Care Services, and Chief Financial Officer.

Observed in Building Tour. The fire extinguisher on the second floor was installed at greater than 60. Observed by the Hospice Administrator. 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 Document Review. Annual fire alarm testing documents did not include the required NFPA code and edition. Observed by the Hospice Administrator.

Observed in Emergency Management Session. The Emergency Operations plan did not describe how they would obtain and replenish medical supplies in response to an emergency. This was discussed with the Executive Director. Observed in Emergency Management Session. The Emergency Operations plan did not describe how they would obtain and replenish medications and related supplies in response to an emergency. This was discussed with the Executive Director.

Observed in Emergency Management Session. The Emergency Operations plan did not describe how they would manage patients and staff who the agency was unable to contact during an emergency. This was discussed with the Executive Director.

Observed in Record Review. In 4 of 16 patient records reviewed, the plans of care did not include measurable outcomes and target dates within which the established goals were to be met. This was discussed with the DON. (RR#1, 3, 5; HV#1)

Observed in Record Review. In 10 of 16 patient records reviewed, the plans of care did not include measurable outcomes to identify how the established goals would be met as required by regulation. This was discussed with the DON. (RR#2, 4, 7, 8, 9, 10, 11, 12 and HV#2, 3).

Observed in Patient Home. During a wound care procedure at home visit HV#4 with the LVN, she dropped the roll of adhesive tape, pick it up off the floor, placed it on her clean barrier with the dressing supplies and did not change her gloves. When it came time to tape the dressing onto the patient, the nurse did not strip of a layer of the tape and discard it but rather just cut it to size and taped the gauge dressing to the patient with the section that had been on the floor. This was also observed by the clinical supervisor.

Observed in Patient Home. During medication review with the clinical manager at home visit #1, there were several medication discrepancies found. For example: the comfort kit had 3 expired medications in it - acetaminophen suppository, Bisacodyl suppository and ondansetron. then found in other rooms in the home were 10 medications that were not on the MAR (medication administration record) - nystatin powder which expired 2 years ago; Mentholated topical cream, Vick's vapor rub, Fleet glycerin suppositories, Thera tears eye drops, A & D ointment, nasal spray, barrier cream, Metra repair cream; periwash and no rinse spray; 02 had been ordered continuously but was not being used.

Observed in Document Review. In 3 of 5 contracts reviewed, there was no language in the contracts communicating the expectations of the agency for the contractors and that the contractors would be evaluated against these established criteria. This was discussed with the Executive director and the DON. (pharmacy, transportation and rehab (PT).

Observed in Building Tour. In discussion with the facility's managers and the executive director for hospice, they stated that the IPU is not conducting environmental risk assessment tours to identify possible safety and security issues which may have an effect on patients, staff and visitors to their facility as required by regulation.

Observed in Document Review. In review of the agency's contract for rehabilitation (PT), the contractor did not state that they would obtain criminal background checks on their therapists as required by regulation. This was discussed with the Executive Director an the DON.