Every finding on record at Hospice Specialty, Inc.

Observed in Record Review. In 3 of 14 patient records reviewed, The organization did not provide the patient with care, treatment, or services according to the patient's individualized plan of care. During review of records 2, 3, and 4 it was noted that physician orders for frequency did not match visits provided. For example in record 2 nursing was ordered 2-3 times per week but was provided once per week in a one week period and in record 3 nursing was ordered 2-3 times per week and was provided 1 x per week for a five week period. This was confirmed by the administrator.

Observed in Individual Tracer. The organization did not implement the infection prevention and control activities it has planned. During home visit 3 the LVN was observed to not cleanse his hands appropriately between patient care steps. For example he did not cleanse his hands after picking up the trash bag and before donning new gloves before beginning the dressing change. This was confirmed by the Administrator.

Observed in Record Review. In 5 of 14 patient records reviewed, The hospice aide did not provide services that are ordered by the physician or allowed practitioner in the plan of care, consistent with the aide’s training, and that the aide is permitted to perform under state law. During review of records 1, 2, 3,4, 9, it was noted that the aide did not follow the plan of care created by the RN. For example in record 1 the aide plan required peri care, ambulation and assist with transfer but these were not documented, and in record 2 the aide documented skin care and shampoo but these tasks were not on the plan of care. This was confirmed by the Administrator.

Observed in Record Review. In 10 of 14 patient records reviewed, For hospices that elect to use The Joint Commission deemed status option: The medical director, physician member of the interdisciplinary team, or physician designee reviews the clinical information for each hospice patient and provides written certification that the patient’s life expectancy is six months or less if the illness runs its normal course. Note: The determination of the patient’s life expectancy considers the following factors: - The primary terminal condition - Related diagnoses, if any - Current subjective and objective medical findings - Current medication and treatment orders - Information about the medical management of the patient’s conditions unrelated to the terminal condition During review of records 1-10 it was noted that there was no certification of terminal illness signed and dated by the physician. This was confirmed by the Administrator.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization failed to ensure the patient's plan of care had goals and interventions based on the problems identified in the comprehensive assessment. For example: In HV#2 the chaplain conducted a comprehensive assessment and established a frequency for visits however there was no spiritual care plan established. This observation was reviewed with the Administrator and the Administrator Designee.

Observed in Record Review. In 9 of 11 patient records reviewed, the organization failed to conduct IDG meeting to review, revise and document the individualized plan no less frequently that every 15 calendar days. For example in RR#4 the 1st and only IDG meeting took place 20 days after admission. In HV#2 there were multiple 20 to 20 plus day gaps between IDG meetings. In RR#6 there has been no IDG meeting to date, now 19 days post admission. RR#9 notes similar gaps between IDG meeting. Similar gaps in IDG meetings are seen throughout records reviewed. Upon discussion with the Administrator and Designee a binder of sign in sheets for IDG meetings was produced, however discrepancies between the sign in sheets and the meeting documentation in the electronic record were noted. Examples of discrepancies were sign in sheets for meetings with no record of the meeting and the topics discussed in that meeting in the patient chart. Another example was sign in sheets for one day and meeting documentation in the record for another day. These observations were reviewed with the Administrator and the Administrator Designee.

Observed in Record Review. In 4 of 11 patient records reviewed, it was noted that the plan of care did not contain revisions based upon the updated comprehensive assessment. The finding of no update noted progress toward outcomes and goals was noted as a pattern throughout all clinical records reviewed. For example: in HV#2 the pain care plan goal stated patient will be comfortable and have pain less that 3/10 within 2 weeks. The goal and its interventions were established on admission and remain unchanged to date spanning 2 benefit periods. Similar findings can be noted on the skin integrity, bowel elimination, musculoskeletal, and respiratory care plans. This observation was reviewed with the Administrator and Administrator Designee. Observed in Record Review. In 4 of 11 patient records reviewed, it was noted that the plan of care did not contain revisions based upon the updated comprehensive assessment. The finding of no update noted progress toward outcomes and goals was noted as a pattern throughout all clinical records reviewed. For example: in HV#2 the pain care plan goal stated patient will be comfortable and have pain less that 3/10 within 2 weeks. The goal and its interventions were established on admission and remain unchanged to date spanning 2 benefit periods. Similar findings can be noted on the skin integrity, bowel elimination, musculoskeletal, and respiratory care plans. This observation was reviewed with the Administrator and Administrator Designee.

Observed in Record Review. In 1 of 11 patient records reviewed, the organization failed to provide patient with care according to the plan of care. For example: in RR#7 the patient santyl was added to the patient's medication profile for wound care in week 6. This change to the wound care regimen was not reflected in the patients plan of care to date as the old dressing change order is still noted in the current care plan. This observation was reviewed with the Administrator and Administrator Designee. Observed in Record Review. In 2 of 11 patient records reviewed, The organization failed to assess the patient's pain according to established policy. For example: in RR#9 and RR#6 the comprehensive assessment noted that pain was an active problem yet the comprehensive pain assessment was incomplete with no assessment of pain description, duration, of side effects (affect on quality of life). This observation was reviewed with the Administrator and the Administrator Designee. Observed in Record Review. In 5 of 11 patient records reviewed, the organization failed to provide services in accordance with established frequencies as stated in the plan of care. For example: in RR#4 the SN frequency is stated as 2-4 times a week. In week 4 patient was seen by the skilled nurse only once, week 5 had no skilled nurse visit, week 6 had one visit, and week 7 had no visit recorded. In HV#2 similar findings of missed frequency with one visit in week 8 and 9, and no skilled nurse visit noted in week 11. Example 2: In RR#4 and HV#2 the hospice aide was assigned to provide skin care on multiple occasions yet there was no explanation or report of the task not completed to the RN, there were other examples of failure to provide perineal care in week 6 with no explanation or report to the RN. Example #3: In RR#9 the plan of care notes a chaplain frequency of 1-2 times a month and 2 PRN visits yet the record reveals no assessment, or visits. Documentation noted the spiritual services were declined, yet the frequency remained part of the plan of care throughout the patient's time of service. As similar finding with the chaplain was also noted in RR#5. In HV#1 the aide was discontinued in July however the plan of care continued to show a frequency until the end of October. These observations were reviewed with the Administrator and the Administrator Designee.

Observed in Record Review. In 5 of 11 patient records reviewed, The RN failed to provide specific written patient care instructions for the hospice aide. For example: in RR#4, for multiple tasks on the aide assignment, no frequency of the task was noted and the assignment such as comb hair, nail care, and partial bath/shower, stating to provide per family request. Turn or position and range of motion is noted as per request. Similar issues with no frequencies and per request tasks were noted in HV#1, HV#2, RR#6 and RR#9. Further the patient had wounds with dressings and no written instructions of how to handle the dressing during visit were noted. These observations were reviewed with the Administrator and the Administrator Designee.

Observed in Record Review. In 3 of 11 patient records reviewed, The organization failed to ensure the medical director review the clinical information for each hospice patient and provide written certification. For example: in RR#9, HV#3, and RR#7 there is no initial certificate of terminal illness noted on the record. It is also noted that the records review that included initial terminal illness statements were recorded on a form for face to face visits lacking pertinent information such as the benefit period, and review of the medical record. This observation was reviewed with the Administrator and the Administrator Designee.

Observed in Record Review. In 2 of 11 patient records reviewed, The organization failed to ensure the patient record contained pertinent clinical information and responses to services. For example: in RR#4 a nursing note in week 4 notes that the medical director did a home visit in the previous week. There was no documentation of the visit in the clinical record. Example two: in RR#7 in week 11 an order for fecal occult blood was noted on the record. There is no indication on the record that this test was completed nor any follow-up documented. This observation was reviewed with the Administrator and the Administrator Designee.

Observed in Record Review. In 3 of 11 patient records reviewed, the organization failed to ensure the certificate of terminal illness was documented and housed with the clinical record upon recertification. In RR#7 no recertification CTI was noted in the record. For RR#5 the CTI was noted in the record for benefit period 16 but was signed 20 days prior to the start of the BP out of compliance with the up to 15 days before the start of the next benefit period guideline. In HV#3 the certification was signed 22 days prior to the next benefit period. The forms the organization use are face to face forms that lack required information such as the benefit period and dates and statement noting the narrative was composed personally and was based on his/her review of the medical record and/or examination of the patient. These observations were reviewed with the Administrator and the Administrator Designee.

Observed in Record Review. In 1 of 11 patient records reviewed, The organization failed to maintain an accurate medication profile in the patient record. For example: upon review of the medication profile for RR#6 the medication profiles listed Oxygen permeable lens product solution where instructions for the solution were 2-4 ml per n/c as needed for shortness of breath. Upon discussion with the Administrator and Designee it was noted the medication should read Oxygen 2-4 liters per n/c. In another entry, polymyxin B Sulfate injection solution is noted to be given in the eyes. Upon discussion with the Administrator was told it should be ophthalmic solution instead of injection solution. Also primidone listed Diabetes as indication yet primidone is a anticonvulsant. These observations were reviewed with the Administrator and the Administrator Designee.