Every finding on record at Liberty Hospice, Inc.

Upon patient record review, 10 of 14 (Patient #1,2,3,4,5,6,7,8,9,10) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #1,2,3,4,5,6,7,8,9,10, No evidence of funeral home documented on psychosocial assessment. No evidence of funeral home plans documented on care plan.

Upon patient record review, 10 of 14 (Patient #1,2,3,4,5,6,7,8,9,10) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #1,2,3,4,5,6,7,8,9,10, No evidence of update for MSW and SC of patient in IDG documentation. IDG update states SC will continue working on enhancing spiritual strategies and providing spiritual support to patient and family. MSW will continue working on enhancing coping strategies and will continue to provide psychosocial support to the patient and family. No evidence of how the patient and family is progressing towards outcome/goals of these items.

Observed in Record Review. In 2 of 11 patient records reviewed, the surveyor observed that the organization did not update the comprehensive assessment every 15 days . Observed during active record review #7, the RN assessment was completed every 21 days not every 15 days as required by agency policy 2-030. The QAPI Manager stated the organization was using the CMS waiver to complete the RN assessments every 21 days. The LVN was going weekly. The need to use the CMS waiver was not applied to all patients and there was not documentation at IDG notes of applying the CMS waiver. Additionally, in active RR#8, the nurse had been completing assessments every 21 day since January 2021. However, other disciplines were making weekly and monthly visits. The RN was not completing on going comprehensive assessments every 15 days as required by agency policy. The QAPI manager stated the agency was following the CMS waiver, however, the CMS waiver was not applied to all patients. These observations were discussed and verified with the Administrator and QAPI Manager.

Observed in Individual Tracer. In 1 of 3 home visits conducted, the surveyor observed that the organization did not follow standards precaution related to hand hygiene. Observed in home visit #2, the clinician did not follow agency hand hygiene policy between glove changes or before entering the clean areas of the nursing bag. The clinician was observed changing gloves several times without performing hand hygiene. Additionally, the clinician did not perform hand hygiene before entering the clean area of her nursing bag. This observation was discussed and verified with the Administrator and QAPI Manager. Observed in Individual Tracer. In 1 of 3 home visits conducted, the surveyor observed that organization did not implements infection prevention and control activities when doing the following: Cleaning and performing disinfection of medical supplies and devices. Observed in home visit #2, the clinician did not know the wet time for the Lysol wipes used to clean BP cuff, stethoscope, pulse oximeter and thermometer. The clinician stated the wet time was 15 second, however, the package stated wet time was 4 minutes The clinician also stated she wraps the equipment with wipes in her car to leave them wet between patients and at the end of the day, she sprays the items with disinfecting spray when she get home. Agency policy states the clinician is to follow manufacture recommendation for wet time. This observation was discussed and verified with the Administrator and QAPI Manager.

Observed in Record Review. In 1 of 11 patient records reviewed, the surveyor observed that the patient record did not clinical information related to specific notes on care, treatment, or services. Observed in active record review #2, there were no Aide notes for over 16 days. The Aide frequency was 2 times a week since the week of 11/28/21. This observation was reviewed and verified with the QAPI Manager and Administrator. The Administrator spoke to the staff member and discovered the Aide had been locked out of the Electronic Medical Record and was unable to enter information. The Aide had not notified the agency regarding this issue prior to surveyor being on site.