Every finding on record at Il Comporto Hospice, Inc.

Observed in Record Review. In 10 of 10 patient records reviewed, for active patients, the nurse surveyor noted that the goals were not consistently measurable. For example, “Pain will remain in comfortable level during care” and Facilitate Bowel elimination and comfort. There were no short-term goals at start of care to address issues of immediate needs such as understanding medication management, symptom management, pain management, or safety, most time frames for completion were at end of certification period and target dates are not being consistently updated. Finding was confirmed by the Office Manager and the Administrator/DPCS Designee.

Observed in Surveyor review but corrected onsite pending acceptable Evidence of Standards Compliance. In 2 of 7 patient records reviewed, with a Hospice Aide it was noted by the nurse surveyor that Hospice Aide Supervisory visits were not documented the required every fourteen days. For RRNHV#2 the HHA Supervisory visit was 7 days late and for RRNHV#6, the HHA Supervisory visit was 8 days late. Findings were verified with the Office Manager and the Administrator/DPCS Designee.

Observed in Tracer Activities. It was noted by the nurse surveyor that the Volunteer Coordinator did not document retention activities that he did with/for his volunteers. Finding was discussed with the Administrator/DPCS Designee and Office Manager.

Observed in Record Review. In 10 of 10 patient records reviewed, it was noted by the nurse surveyor that entries into the electronic medical record by the skilled nurse and social worker for RRHV#1, RRNHV#2, and RRNHV#4 were not made within the organizations’ defined time frame of 48 hours (Submission of Notes, Policy No 2-005 1A). Additionally, numerous notes in all of the records reviewed did not have the final sign-off by Quality Assurance (QA) which completes the note and affixes the final electronic signature. Some were more than a month without QA review. Finding was verified by the Office Manager and the Adminstrator/DPCS Designee.

Observed in Record Review. In 1 of 1 patient records reviewed, for live discharge due to extended prognosis, it was noted by the nurse surveyor that the Hospice did not have a process in place to ensure that a Notice of Medicare Non-Coverage (NOMNC) was signed by the patient or patient’s representative at least two days prior to a planned discharge as required. For RRDC#1, the patient was discharged for extended prognosis, NOMNC was signed by the patient’s daughter on the day of discharge even though discharge planning had begun a week prior and was documented in the EMR. Additionally, the NOMNC form did not include the phone number or name of the agency’s Quality Improvement Organization (QIO). Finding was discussed with the Administrator/Director of Patient Care Services, Designee and the Office Manager.

Observed in Record Review. In 1 of 5 patient records reviewed, The organization failed to ensure the patient/primary caregiver receive education and training as appropriate for new medications ordered. For example: Upon review of RR#3 a comfort kit was ordered on day 3. There were no indications in the record that education was provided on the medication, type, indication, route, dose, frequency, or potential side effects for the medications ordered in the comfort kit. This observation was reviewed with the Administrator, and the Compliance Officer.

Observed in Patient Home. In 1 of 1 home observations conducted by the hospice aide, the aide failed to follow the established hospice aide assignment. For example: the hospice aide assignment specifies the patient was to transferred with 2 person assist. When observing the aide providing care, the aide transferred the patient onto the shower chair without the assistance of a second person. This observation was reviewed with the Administrator and the Compliance Officer.

Observed in Patient Home. In 1 of 2 home visits conducted, Staff failed to perform hand hygiene consistent with CDC guidelines adopted per organization. For example: during HV#1 the aide failed to cleanse hands between glove changes while providing patient shower. This observation was reviewed with the Administrator.

Observed in HR File Review. In 1 of 1 Hospice Aide HR files reviewed it was noted the organization failed to fully complete the competency evaluation by observing an aides performance for appropriate and safe techniques with a patient. For example: the aide initial competency was initiated upon hire with observations of temperature, hand washing and bag technique and followed up 2 months later with observation of chair to standing transfer and use of walker. Shower/tub bath skills were evaluated via written method. Other skills such as bed bath, nail care, and oral care, elimination and positioning are left unaddressed. This observation was reviewed with the Administrator, and Compliance Officer. Observed in HR File Review. In 1 of 1 Hospice Aide HR Files reviewed it was noted that the organization failed to complete the initial competency assessment skills checklist for Hospice Aide. For example: upon hire the aide competency was initiated and the aide completed the self assessment. There are signed evaluations of written, verbal, or observation for temperature, relates to POC, RN reporting, performs services as ordered, communicates/coordinates, patient safety/fall risk, and eye contact/active listening. All other competency validations are left blank. This observation was reviewed with the Administrator and Compliance Officer.

Observed in HR File Review. In 6 of 8 HR files reviewed, The organization failed to fully complete staff competencies upon hire and document with orientation. For example: Initial competency assessment skills checklist for MSW/Bereavement Coordinator, LGSW, Chaplain, Administrator Designee, LVN, were initiated upon hire, the self assessment completed, and some tasks were addressed although many tasks remained unaddressed and thus incomplete. This observation was reviewed with the Administrator and Compliance Officer.