Every finding on record at Jackson County Schneck Memorial Hospital

Observed in Record Review. In 7 of 14 patient records reviewed, the hospice goals were not individualized to meet the patients' needs based on the assessments. All of the goals listed for Hosp RR#2, RR#3, #4, #5 #7, #8 and #10 included the following target dates- In Progress. This observation was discussed with the director.

Observed in Record Review. In 1 of 14 patient records reviewed, did not have all interventions included on the comprehensive care plan based on the assessment. Bereavement RR#1 had a Foley and the comprehensive hospice care plan did not include orders for the Foley related to the size of the catheter, balloon size, or frequency of change. This observation was discussed with the director.

Observed in Individual Tracer. In 1 of 14 patient records reviewed, the hospice plan of care goals were not revised based on the comprehensive assessment. Hosp RR#1 HV had 5 recertification periods. The initial certification period had the following goal-Patient will describe measures to protect skin/ wound care teach back within 48 hours. This goal remained on the current certification plan of care. This observation was discussed with the director.

Observed in Leadership Session. Based on a review of the available data there was no comprehensive QAPI plan for 2024. There were several projects however these projects did not reflect the complexity of the services provided by the hospice. For example, the data collection/analysis did not address volunteer services, bereavement services, contract oversight, and or the levels of care specifically continuous care. This was discussed with the director.

Observed in Tracer Activities. There was no identification of the frequency of data collection/reporting/ and or analysis of required data points therefore limited opportunities to internally benchmark and reprioritize performance improvement initiatives as necessary in 2024 or 2025. This observation was discussed with the director.

Observed in Data Session. Based on a review of the available data, the hospice and home care only collected hand hygiene data on the nursing staff. These programs provided therapy, chaplain, social work , and volunteer services to patients. This observation was discussed with the director.

Observed in Individual Tracer. In 2 of 6 patient records reviewed, that had a hospice aide, the care plan did not reflect all of the written instructions required by on the assessment. RR#1 had a colostomy and this device was not reflected on the care plan. Hos RR#12 had multiple wounds and the aide care plan did not reflect wound precautions. This observation was discussed with the director.

Observed in Leadership Session. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by condition level deficiencies - 418.100, 418.56, and 418.58.

Observed in Leadership Session. Based on a review of admission data provided to patients, there was no process in place to educate patients related to all levels of hospice care. While the policy specifically detailed continuous care as a option under the hospice benefit, this language did not appear in patient data given. Additionally, per the director, continuous care has not been provided within the past 3 years due to staffing. There was no discussion of continuous care in the QAPI minutes and or annual evaluation.

Observed in HR File Review. In 1 of 8 HR files reviewed, did not have discipline specific competencies. HR#5 was a hospice social worker and there were no competencies completed and or developed that addressed her specific duties. The competency completed was general. Additionally, this social worker also functioned as the bereavement coordinator and there was no specific competencies defined for this role. This observation was discussed with the director.

Observed in Individual Tracer. In 1 of 14 patient records reviewed, entries in the hospice record were not appropriately authenticated. Two consent forms in Hosp RR#1 were signed but not dated. This observation was discussed with the director.

Observed in Record Review. In 1 of 2 patient records reviewed, that were live discharges, did not provide the discharge summary to the next provider. DC RR#1 was transferred to another hospice and there was no transfer/discharge summary or documentation in the record that this summary was provided to the receiving hospice. This observation was discussed with the director.

Observed in Patient Home. In 1 of 2 patient records reviewed, that resided in a nursing home, did not have updated hospice documents in the facility. Hosp RR#1 HV has been recerted 5 times and only the initial certification plan of care was located in the nursing home chart. This was discussed with the RN.

Observed in Tracer Activities. In 1 of 2 tracers conducted, did not have appropriate language in the contract. The nursing home contract did not have a stipulation that the criminal background checks would be obtained for all employees that have patient contact. This observation was discussed with the director.

Observed in Tracer Activities. During the admission packet review it was noted that while the organization provided written information on advance directives it failed provide written information to the patient concerning its policies on advance directives. This observation was reviewed with the Hospice Scribe.

Observed in Record Review. In 3 of 13 patient records reviewed, the organization failed to document a patient-specific comprehensive assessment as related to the management of the terminal illness and the severity of symptoms. For example: in review of HOS RR#6 the hospice surveyor noted the patient was admitted with COPD however in the admission assessment there was no documentation specific to respiratory and cardiovascular systems. A similar example can be see in HOS RR#8 where the patient was admitted with Lung Cancer yet no documentation specific to respiratory and cardiovascular systems is noted. In HOS-RR#8 there was mentioned of milky colored urine in the initial comprehensive assessment however there was no further assessment of the urinary system. In HOS-RR#13 there was mention in the initial comprehensive assessment of the presence of a foley catheter yet no assessment of the urinary system noted in the record. There was a statement in all records reviewed that stated Assessment: Head to toe: Within patient expected range with the following exceptions noted in care plan below - Complete: yes. This observation was reviewed with the Hospice Scribe.

Observed in Record Review. In 1 of 13 patient records reviewed, the organization failed to maintain a complete and accurate patient record. For example: upon review of record for HOS HV#2, the hospice surveyor noted there were multiple documents for another patient filed in the record. This observation was reviewed with the hospice scribe.

Observed in Record Review. In 5 of 13 patient records reviewed, the organization did not ensure that the individualized plan of care reflected patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. For example: Upon review of HOS HV#2 and HOS RR#9 by the hospice surveyor, a significant issue for the patient and family was noted to be nutritional status yet this issue was not reflected in the plan of care. For HOS HV#3, and HOS RR#12, the patient was noted to be declining to end of life, however there was no care plan to address death and dying. In HOS RR#7 the patient had aspiration pneumonia upon admission yet the infection was not addressed in the plan of care. These observations were reviewed with the Hospice Scribe.

Observed in Tracer Activities. During the bereavement program review the hospice surveyor noted that the bereavement plans of care called for multiple mailings, however there was no documentation in the record to verify that the mailings were sent. This is in violation with the organization policy for bereavement services that states all visits, telephone calls and written communication with the bereaved is documented, dated, filed and maintained in respective bereavement care files. This observation was reviewed with the Hospice Scribe.

Observed in Record Review. In 1 of 13 patient records reviewed, The organization failed to provide for and ensure the ongoing sharing of information between disciplines providing care and services. For example: upon review of HOS RR#5 by the hospice surveyor it was noted that the patient had an episode where the foley was traumatically removed with the balloon intact, and then reinserted with no urine return. Although a follow up RN visit was made, there is no indication in the record that the MD was notified of the issues with the foley replacement. This observation was reviewed with the Hospice Scribe.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to implement the infection prevention and control activities it has planned. For example: in HOS HV#1 and HOS HV#2 the nursing bag utilized by the Registered Nurses failed to contain separated clean and dirty compartments as specified in the organization bag technique policy. This observation was reviewed with the Hospice Scribe.

Observed in Record Review. In 4 of 13 patient records reviewed, the registered nurse failed to provide the hospice aide with specific written patient care instructions. For example: upon review by the hospice surveyor of HOS HV#3 the patient had a wound dressings on the sacrum and ankle however there were no written instructions for the aide on how to handle the dressings during a bath. Example 2: in HOS RR#4 the aide assignment for bath stated May give whichever type patient prefers and will tolerate. Example 3: In review of HOS RR#5 the patient had a foley catheter, There was a task for emptying the foley collection bag, yet no foley care assigned. A similar finding can be seen in HOS RR#8. These observations were reviewed with the Hospice Scribe.

Observed in Record Review. In 2 of 13 patient records reviewed, The organization failed to ensure the patient record contained pertinent documentation of responses to medications, symptom management, treatments, and services. For example: upon review of HOS RR#5 and HOS RR# 8 by the hospice surveyor, there was a lack of specific documentation related to foley insertion to include type of procedure, specific technique and steps used to insert. This observation was reviewed with the Hospice Scribe.

Observed in Patient Home. In 2 of 13 patient records reviewed, the organization failed to maintain an accurate medication profile for the patient record. For example: in home observation for HOS HV#1 the hospice surveyor noted that the patient's medication contained two bottles of acetaminophen of differing strengths, one bottle for 325mg and another of 650mg tablets. The medication profile shows the order as 325mg 1 - 2 tabs every 6 hours as needed for pain. Example 2: upon review of HOS RR#10 the patient was prescribed Morphine IR for pain, and then later the medication was discontinued. THis medication and its use was not reflected on the patient's medication profile. This observation was reviewed with the Hospice Scribe.