Every finding on record at Hutto Hospice Inc.

Observed in Record Review. In 3 of 3 patient records reviewed, the organization failed to ensure the development of an individualized written plan of care with goals that were specific, measurable, and time-bound. Throughout the records reviewed there were goals established that lacked being specific, measurable and time-bound. For example: in RRHV#1 examples of goals were Patient's pain will be managed at a tolerable level to patient and CG with medications, O2 and comfort measures and patient will maintain optimal oxygenation within disease process, with all goals being noted as achieved within 1 certification period. In RRHV#2 examples were Foley catheter will be properly cared for – by time of death or discharge and Patient/family/facility staff will be educated on emergency preparedness – by time of death or discharge. In RRHV#3 examples were Patient will maintain optimal oxygenation within disease process. and patient and caregiver will develop coping skills to help cope with patients terminal diagnosis – within 0-24 hrs. Throughout the records reviewed many of the time-frames were not noted to be realistic or individualized to the patient's needs. These observations were reviewed with the Alt Administrator/Director of Nursing, RN and the Compliance Officer.

Observed in Record Review. In 3 of 3 patient records reviewed, the organization failed to ensure the plan of care included all services needed for the palliation and management of the terminal illness and related conditions including drugs and treatment necessary to meet the needs of the patient. For example: on review of RRHV#1, RRHV#2, and RRHV#3 the patients medication profile included Morphine as needed that was ordered 0.25 ml to 1 ml SL every hour as needed for pain/shortness of breath yet there were no instructions to guide the patient/caregiver which dosage to give for what specified pain level. Further, in RRHV#3 the patient was also ordered tramadol, yet there were no instructions to guide administration as to when to give which medication. These observations were reviewed with the Alt Administrator/Director of Nursing and RN.

Observed in Infection Control Tracer. The organization failed to set goals to minimize the possibility of spreading infections that included limiting the spread of infections associated with procedures, as the leadership was unable to produce evidence of goal established at time of survey. This observation was reviewed with the Alt. Administrator/DON, RN and Compliance Officer. Observed in Infection Control Tracer. The organization failed to set goals to minimize the possibility of spreading infections that included improving compliance with hand hygiene guidelines, as the leadership was unable to produce evidence of goal established at time of survey. There was evidence of a hand hygiene program with surveillance, yet no goals for improvement established. This observation was reviewed with the Alt. Administrator/DON, RN and Compliance Officer. Observed in Infection Control Tracer. The organization failed to set goals to minimize the possibility of spreading infections that included limiting the spread of infections associated with the use of medical equipment, devices, and supplies, as the leadership was unable to produce evidence of goal established at time of survey. This observation was reviewed with the Alt. Administrator/DON, RN and Compliance Officer.