Every finding on record at Johnston Health Services Corporation

Observed in Record Review. In 4 of 17 patient records reviewed, the Hospice Nurse Surveyor noted the chaplain failed to complete their initial assessments within five days after the election of hospice (EOHB). For example, in HOSRRHV2, the Chaplain had not reached out to schedule initial visit until 6 days post EOHB. In HOSRRNHV1, the Chaplain made an initial phone call to schedule a visit with the patient 6 days post election of hospice. In HOSRRNHV6, the Chaplain did not document an initial contact with the patient until 13 days post EOHB. In HOSRRNHV8, there had been no documented Chaplain contact for 9 day post EOHB. This was validated with the Quality Coordinator.

Observed in Record Review. In 2 of 14 patient records reviewed, the Hospice Nurse Surveyor noted patient wounds had not been assessed according to agency policy which states: wounds are measured on admission and at least once a week. For example, HOSRRHV3, the patient had a documented stage 3 pressure injury receiving care; however, there had been no assessment of wound on admission to hospice nor the 3 weeks of ongoing care and service. In HOSRRNHV3, there had been no documentation of the wound assessment and measurements in 3 months. This was validated with the Director of Hospice.

Observed in Patient Home. In 2 of 4 home visits conducted, the Hospice Nurse Surveyor noted care had not been provided according to hospice plan of care. For example, in HOSRRHV4, the patient had orders for Peritoneal Drainage Catheter: drain 2x/week during SN visit and PRN; however, the RN had not been observed to drain the peritoneum. Per the RN, she is only draining the peritoneum weekly. This was validated with the Quality Coordinator present during the visit.

Observed in Building Tour. There were two (2) H-Cylinders that were located in the bulk oxygen tank area that were not covered being protected from the elements. This was observed by the Director of Facility Engineering, the Manager of Facility Maintenance, and the Emergency Management Coordinator/Safety Officer. Observed in Building Tour. The generator was unsecured giving access to unauthorized personnel. This was observed by the Director of Facility Engineering, the Manager of Facility Maintenance, and the Emergency Management Coordinator/Safety Officer.

Observed in Building Tour. There was an escutcheon plate that was not properly installed leaving a gap greater than 1/8 inch from the escutcheon plate to the ceiling. This was located in the Family Living Room. This was observed by the Director of Facility Engineering, the Manager of Facility Maintenance, and the Emergency Management Coordinator/Safety Officer. 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 Record Review. In 2 of 10 patient records reviewed, for active patients it was noted by the nurse surveyor that for HOSHV#1/RR#1, the Chaplain completed the comprehensive assessment six days after the election of hospice care. There was no documentation in the electronic medical record to indicate why the visit was not completed within the required time frame. For HOSHV#2/RR#2, the Chaplain completed the comprehensive assessment ten days after the election of hospice care. There was no documentation in the electronic medical record to indicate why the visit was not completed within the required time frame. This was verified by the QA Nurse.

Observed in Record Review. In 1 of 10 patient records reviewed, for active patients. It was noted by the nurse surveyor that for HOSHV/RR#2 the goals were not consistently measurable. For example, “Pain will be at an acceptable level” additionally most goals did not have time frames for completion. Findings were validated with the Quality Nurse.

Observed in Record Review. In 2 of 10 patient records reviewed, for active hospice patients, it was noted by the nurse surveyor that the plan of care did not specify all care and services necessary. In HOSHV#1/RR#2, the plan of care did not address the patient’s pain or the patient's goals for pain control. In HOSRR#4, the plan of care did not include anything regarding the care or assessment of the patient’s colostomy or biliary tube that were a result of her surgery for metastatic colon cancer. The findings were verified by the QA Nurse.

Observed in Tracer Activities. In 1 of 1 tracers conducted, for a medication pass in the IPU, the nurse surveyor noted that there were some breaks in hand hygiene Policy#12501963. The nurse dropped the Morphine cartridge on the floor then did not wipe it off and did not perform hand hygiene. She then gathered her supplies and proceeded to the patient's room. Upon entering the room, she performed hand hygiene and donned gloves. The nurse then set all of her supplies on the overbed table without cleaning the table or laying down a barrier. She then prepared the IV medication for administration and administered the IV medication without changing her gloves or performing hand hygiene. Observed in Patient Home. In 1 of 3 home visits conducted, it was observed by the Nurse Surveyor that the organization did not implement the infection prevention and control activities it had planned per hand hygiene Policy#12501963. During HOSHV#3/RR#3 the nurse orientee stopped documenting on the computer on several occasions to help the skilled nurse raise the patient up in the bed so that the patient’s lung sounds could be heard. The nurse orientee did not hand sanitize before or after touching the patient and went back to documenting on the computer. The break in hand hygiene was also noted by the QA Nurse who was present on the home visit.

Observed in Leadership Session. During review of the organization's infection control plan and documents, there was no documentation to validate the plan included goals related to limiting the spread of infections associated with the use of medical supplies. This was reviewed and validated with leadership. Observed in Infection Control System Tracer. During review of the organization's infection control plan and documents, there was no documentation to validate the plan included goals related to limiting unprotected exposure to pathogens. This was reviewed and validated with leadership. Observed in Infection Control System Tracer. During review of the organization's infection control plan and documents, there was no documentation to validate the plan included goals related to limiting the spread of infections associated with procedures. This was reviewed and validated with leadership. Observed in Infection Control System Tracer. During review of the organization's infection control plan and documents, there was no documentation to validate the plan included goals related to improving compliance with hand hygiene. Following the Infection Control session, a goal of 90% was presented with combined aggregated data for both home health and hospice for 2021 results reflecting 94% compliance and 2022 results reflecting 87% compliance; however, leadership was not aware of the decrease in compliance as they were not tracking and trending their hand hygiene compliance data prior to survey. This was reviewed and validated with leadership. Observed in Infection Control System Tracer. During review of the organization's infection control plan and documents, there was no documentation to validate the plan included goals related to addressing its prioritized risks. This was reviewed and validated with leadership.

Observed in Patient Home. In 1 of 1 home visits conducted, with the hospice aide, It was noted by the nurse surveyor that for HOSHV#1/RR#1 the hospice aide did not provide care according to the hospice aide plan of care. The hospice aide care plan instructed the hospice aide to assist the patient with a shower however, during the home visit the patient and the patient caregiver stated that the hospice aide had been performing a chair bath per patient request. Finding was verified by the QA nurse who was present during the visit.

Observed in Tracer Activities. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews: §418.100(c)(1)(i)

Observed in Tracer Activities. In discussion with hospice leadership, it was noted the organization does not offer/provide continuous care as a level of hospice care for symptom management. Per the Hospice Clinical Manager and Hospice In-patient Clinical Manager, they do not have a process nor staffing in place to provide continuous care in the patient's home setting.