Every finding on record at Land of Peace Hospice

Observed in Tracer Activities. The organization did not follow a written policy addressing the privacy of health information. During review of contracts it was noted that the pharmacy and DME contracts did not have a HIPAA business associate agreement associated with them. Their was no specific policy that the organization requires a HIPAA business associate agreement with contracts where the contractee can view HIPAA protected information. This was confirmed by the RN.

Observed in Record Review. In 3 of 13 patient records reviewed, The organization did not respects the patient's right to elect and revoke hospice care, in accordance with Medicare hospice regulations. During review of live discharged patient records 9, 10, and 11, it was noted that revocation statements were not present in the records. This was confirmed by the RN.

Observed in Record Review. In 2 of 14 patient records reviewed, The written plan of care was not based on the patient’s goals and the time frames, settings, and services required to meet those goals. During review of patient records 3 and 7 it was noted that there were no goals related to fall management although the patients had both scored at high risk for falls. This was confirmed by the RN.

Observed in Individual Tracer. In 2 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 home visits 1 and 2 the nurse did not have a paper or computer patient plan of care to refer to. When the surveyor inquired about the patient's plan of care or visit schedule the nurse replied that she did not know. This was discussed with the office manager.

Observed in Individual Tracer. In 2 of 3 home visits conducted, The organization did not reduce the risk of infections associated with medical equipment, devices, and supplies. During home visit 1 and two it was noted that the nurse used a small alcohol swab to clean medical equipment and did not clean the blood pressure cuff as per policy. This was discussed with the Office Manager.

Observed in Tracer Visit. The surveyor observed during home visit 1 that the SN had not completed a pain assessment as per organization policy. The patient had several pain medications in place, and was grimacing during visit, but the SN did not complete the pain reassessment as per organization policy. This issue was discussed and confirmed with organization leadership.

Observed in Individual Tracer. In 3 of 3 home visits conducted, the surveyor observed that the SN in 3/3 cases had not turned patient to examine skin on back side of patient as required by organization policy . The issue was discussed with organization leadership and confirmed as an issue.

Observed in Record Review. In 2 of 5 patient records reviewed, the surveyor found issue with the written plan of care. Surveyor observed on one record that a patient admitted as actively dying and lived 4 weeks, had nothing opened on POC except active dying. The patient and family had multiple other issues that where identified and documented in staff visit notes, but none where identified on POC . On yet another patient record the plan of care had goals created, but all goals identified contained same time frame which was cert period . These issues were discussed and confirmed with leadership.