Every finding on record at Liberty Creek Hospice, LLC

Observed in Tracer Activities. the organization failed to inform and distribute written information to the patient concerning its policies on advance directives, including a description of applicable state law. On review of the admission packet and patient handbook it was noted that the was a document noted that stated I have received written information on state law and the hospice policy advising me of my right to make decisions concerning my medical and formulate Advance Directives, however the written information on state law and policy that the org was presenting to the patients was not available at survey, nor was any written information on advance directives noted the home binders during the patient visits. This observation was reviewed with the Administrator and DPCS.

Observed in Record Review. In 2 of 10 patient records reviewed, the organization failed to document a patient-specific comprehensive assessment and reassessment that identifies the patient’s need for hospice care and services. For example: on review of RRNHV#7 the initial comprehensive assessment noted a wound to the left gluteal fold yet failed to document a wound assessment to include details such as size, drainage, odor and surrounding skin as required, as it only noted possible skin tear or pressure ulcer stage 2 and the color of red. Further, the wound assessment was not consistently documented as required per policy throughout the clinical record. In RRNHV#10 the documentation noted the patient with a Pleurex drain yet there was no documentation noted of the drain site, and surrounding area. These observations were reviewed with the Administrator and DPCS.

Observed in Record Review. In 1 of 10 patient records reviewed, For active records the organization failed to document a patient-specific comprehensive assessment and reassessment that identifies the patient’s need for hospice care and services. For example on review of RRNHV#10 there was no documentation of an initial bereavement risk assessment completed to date of survey. This observation was reviewed with the Administrator and DPCS.

Observed in Record Review. In 10 of 10 patient records reviewed, for active patient records, the organization failed to ensure the plan of care is based on the patient's goals that are specific, measurable, achievable, realistic, and time-bound. Throughout all active records reviewed the plan of care goals lacked being specific, measurable, and time bound. All goals were set to be achieved by the date of the next IDG meeting. For example: in RRNHV#10 examples of goals were caregiver will be knowledgeable on prevention of skin breakdown -Minimize risk for bed sores, wounds/injury for skin maintenance under hospice care. In RRNHV#7 an example was Pt will have optimum level of oxygen- dyspnea will be controlled at a mild level. In RRNHV#5 an example was Pt will exhibit adequate relief with current pain regimen. Further examples can be seen throughout all clinical records. These observations were reviewed with the Administrator and DPCS.

Observed in Record Review. In 8 of 10 patient records reviewed, for active patient records the organization failed to ensure the plan of care includes all services needed for the palliation and management of the terminal illness and related conditions. For example: on review of RRNHV#10 the patient had a Pleurex drain per the assessment documentation, however the presence of the drain was not included on the hospice plan of care. The patient had pain requiring Morphine yet there was no pain care plan established. In RRHV#1 the documentation noted 3 falls, yet the falls were not reflected in the plan of care. In RRHV#2 the documentation noted increased hallucinations, and vomiting, but no care plans established to address the issues documented. In RRHV#3 there was documentation of increased with the addition of Tramadol, however the plan of care did not reflect the changes in patient status. Further, in RRNHV#10, RRNHV#9, RRNHV#8, RRNHV#7, RRNHV#4, RRHV#3 the MSW was seeing the patient yet there was no psychosocial care plan established to guide the care. This observation was reviewed with the DPCS and Administrator.

Observed in Record Review. In 2 of 10 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. For example: on review of RRNHV#8 there was a wound care order that was incomplete and lacked all required elements. It read laceration left forehead, left forearm, and left knee - may apply bacitracin ointment and cleanse with normal saline. The order did not address a frequency, should the wounds be covered or left open to air, and who was to perform the care. RRNHV#7 also had a wound care order that did no include all requirements. It read may cleanse wound with normal saline, use bordered gauze and skin protectant. Example 2: on review of RRNHV#8 the patient plan of care had two pain medications (Morphine and Tramadol) yet there were no specific instructions beyond every 4 hours as needed to guide the patient/caregiver to know which medication to choose for what type of pain. These observations were reviewed with the Administrator and DPCS.

Observed in Patient Home. In 3 of 3 home visits conducted, the organization failed to implement infection prevention and control activities when cleaning and performing and disinfection of medical supplies and devices. For example: on home observation at RRHV#1, the CHHA was observed utilizing a wipe to cleanse equipment used (BP cuff, pulse oximeter) from an unlabeled bag, and returned immediately to the bag without allowing for contact time per the manufacturer guidelines of 4 minutes. When asked the CHHA was type of wipe was used, she noted it was a Clorox wipe. In RRHV#2, and RRHV#3 the RN was observed to cleanse equipment with a disinfecting wipe and return the equipment immediately to the nursing bag not allowing for contact time and dry. On review of the wipe container the manufacturer guidelines specified a 4 minute contact time for disinfection. This observation was reviewed with the DPCS.

Observed in Record Review. In 8 of 10 patient records reviewed, the organization failed to ensure the RN prepare written patient care instructions for the hospice aide. For example: on review of RRNHV#10, the patient had a pleurex drain, however the presence of the drain was no included on the Aide Assignment/Plan of Care to guide the aide in how to handle the drain while providing care. In RRNHV#7 and RRNHV#8 the patient had documentation of a wound, yet there were no instructions to the aide on how to handle the site and/or dressing while providing care. In RRHV#1, RRHV#2, RRHV#3, RRNHV#4 and RRNHV#5 the aide was assigned the task of obtaining vital signs each visit, but there were no parameters noted on the plan of care for guiding the aide when to report readings to the RN. These observations were reviewed with the DPCS, and Administrator.

Observed in Record Review. In 3 of 10 patient records reviewed, the organization failed to provide care, treatment, and services in accordance with orders per the plan of care. During observation of RRHV#1 the hospice aide was observed to assist the patient with a shower to include shampooing the hair, yet the aide plan of care did not assign the aide to shampoo hair. In review of RRNHV#8 there was documentation on the hospice aide visit note that the aide had cut finger and toe nails, yet this task was not assigned to the aide. In RRNHV#6 the aide documented applying non-medicated ointment to patient's great toe and covering with gauze, but the care provided was not assigned to the aide. These observations were reviewed with the DPCS and Administrator.

Observed in Patient Home. In 2 of 2 home visits conducted, where medication reconciliation was observed, the organization failed to ensure the patient record reflect contained information to reflect the patient's care, treatment and services. For example: on observation the medication reconciliation for RRHV#3 there was noted that Lorazepam order on 0.5mg 1 tab every 4 hours was on the patient's plan of care medication profile, yet the medication in the home blister packs were labeled to give every 4 hours as needed. The caregiver at the boarding home verified that the medication was being given as needed and not scheduled. On review of the medication reconciliation for RRHV#3 there was an order on the hospice medication profile for Robafen cough syrup for 10/200 mg 10ml 3 times a day as needed, yet the bottle in the home was for 10/100 mg strength. This observation was reviewed with the DPCS.

Observed in Competency Session. In 2 of 5 contracts reviewed, the organization failed to ensure the written agreement with an outside agency providing contracted services for hospice included all of the required elements. For example: on review of the contracts for DME and pharmacy there was no stipulation noted that the outside agency will complete criminal background checks on contracted employees who provide direct patient care or have access to patient records. This observation was reviewed with the DPCS and Administrator.