Every finding on record at Living Waters Hospice LLC

Observed in Record Review. In 1 of 19 patient records reviewed, the patient assessment did not include the patient's needs for psychosocial and emotional care as required by policy. In the chart for RRNHV#9, the patient was assessed to have depression, multiple losses, disfigurement, history of substance abuse and pain management issues. There was no assessment of suicide risk as required by organizational policy Suicide risk assessment, intervention and care planning for patients exhibiting these issues. This was discussed with the DPCS.

Observed in Record Review. In 1 of 19 patient records reviewed, the patient record did not include information needed to justify the patient's care, treatment or services. In the chart for RRHV#1, the patient had non-verbal signs of pain at the admission visit, so a Fentanyl patch was ordered. Pain was assessed to be none at every subsequent visit during the first benefit period and there was no documentation of education about pain management using a pain patch. The Fentanyl patch was discontinued at the time of the first recert assessment. The record was unclear if the patch had ever been applied. This was discussed with the DPCS.

Observed in Record Review. In 1 of 19 patient records reviewed, the plan of care did not include all services needed for the palliation and management of the terminal illness. In the chart for RRHV#3, the patient was documented upon assessment in the first two nursing visits to be using oxygen prn. There was no oxygen order on the plan of care. This was discussed with the DPCS.

Observed in Record Review. In 1 of 19 patient records reviewed, plan of care revisions did not include progress toward goals and outcomes. In the chart for RRNHV#5, the Social Work documentation in each of the most recent five IDT meetings were the exact same verbiage with the exception of when the patient would be seen again and included no new information about progress toward goals. This was discussed with the DPCS.

Observed in Document Review. In 1 of 3 contracts reviewed, the written agreement with an outside agency providing contracted services for the hospice did not include the following: A stipulation that services may be provided only with the authorization of the hospice. This stipulation was missing in the pharmacy contract. This was discussed with the Administrator.

Observed in HR File Review. In 1 of 8 HR files reviewed, staff had not participated in ongoing education and training. In the file for HR3, there was no documentation of any annual education about Infection Control and Blood Borne Pathogens as required by OSHA. This was verified with the Volunteer Coordinator.

Observed in Record Review. In 2 of 19 patient records reviewed, the patient record did not contain an accurate list of medications. During RRHV#4, it was observed that the list in the hospice EMR and in the patient home did not match what the patient was receiving. The EMR stated Metoprolol 25 mg daily. The caregiver indicated that for more than the past three months, she administers 1/2 of one tablet twice daily which matched the prescription bottle in the home. Additionally, the caregiver indicated that the Midodrine was discontinued more than three months prior to the survey, yet remained on the list in the home as well as in the EMR. This was observed by and discussed with the DPCS present at the visit. In the chart for RRNHV#12, the RN noted the patient had started taking Allegra for itching. This medication had not been added to the plan of care/medication list. This was discussed with the DPCS.

Observed in Record Review. In 1 of 1 patient records with a transfer, when the patient was discharged to another Medicare facility, the hospice had not provided the receiving facility with a copy of the hospice discharge summary. There was no documentation in the record for RRDC#16 that the hospice provided any information to the hospital when the patient revoked the hospice benefit for treatment for a fracture. This was discussed with the DPCS.

Observed in Document Review. In 2 of 3 contracts reviewed, the written agreement with an outside agency providing contracted services for the hospice did not include the following: A stipulation that the contracted entity obtains criminal background checks on contracted employees who have direct patient contact or access to patient records. This stipulation was missing in the pharmacy and DME contracts. This was discussed with the Administrator.

Observed in Record Review. In 7 of 13 patient records reviewed, The hospice surveyor noted the plan of care did not include goals with specific time frames. Upon review of the record for HV1, HV2, HV3, RR 1, RR 2, RR 3 and RR 5, it was noted the time frame for goals developed was documented as the end of the benefit period. For example, on review of the record for HV#1, it was noted the goal for wound healing indicated the wound would heal by the end of the benefit period. In HV2 SW has goals regarding patient access to a phone for emergencies and providing copy of advanced directives, both with goals target time frame end of benefit period. This was reviewed and validated with the Director of Patient Care Services.

Observed in Record Review. In 2 of 13 patient records reviewed, The nurse surveyor noted the plan of care did not include all interventions to meet the patient's needs. Example, in RR7 it was documented on admission that the patient had a foley catheter in place; however, on review of the plan of care, there were no orders/interventions related to catheter care until one month after start of care date. It was noted in RR7 and RR8 the patient's were on a blood thinner, however, on review of the plan of care, there were no interventions related to teaching on bleeding precautions and/or validating the patient/caregiver's understanding of the risk of bleeding related to blood thinner use. This was reviewed and validated with the Director of Patient Care Services.

Observed in Record Review. In 1 of 13 patient records reviewed, The nurse surveyor noted medication/treatment orders were missing and/or incomplete. According to organizational policy Orders for Medications and Treatments No. 3.72, PRN orders must include any special parameters. Upon review of the record for HV#1, it was noted multiple pain medications were ordered; however, the orders did not include directions regarding when each medication should be administered. During the home visit, the patient was noted to be on oxygen therapy; however, there was no order for oxygen documented in the record. This was reviewed and validated with the Director of Patient Care Services.

Observed in Patient Home. In 1 of 3 home visits conducted, Standard precautions were not used to reduce the risk of infection. According to organizational policy Nurse Bag Technique and Trunk Supplies No. 9.44, sanitize hands before entering bag. During HV 3 nurse observed entering nursing bag after touching patient objects with gloves on without first removing gloves and conducting proper hand hygiene. This was discussed and validated with the Director of Patient Care Services following the visits. Observed in Patient Home. In 2 of 3 home visits conducted, Standard precautions were not used to reduce the risk of infection. According to organizational policy Nurse Bag Technique and Trunk Supplies No. 9.44, reusable equipment is to be cleaned using Clorox wipes. During HV#1 and HV#3, the clinicians were observed cleaning their reusable equipment with “Micro Kill One”. According to the manufacturer’s instructions for Micro Kill One, after cleaning equipment should be allowed to dry for one minute. Additionally during HV#3, the clinician was observed cleaning their reusable equipment and immediately placed the equipment back into their bag. This was discussed and validated with the Director of Patient Care Services following the visits.

Observed in Infection Control System Tracer. During data management system tracer nurse surveyor noted the agency had identified prioritized risks but did not develop measurable objective goals related to the identified risks. An example of goals set include to limit the spread of infections associated with procedures, however this goal did not have a measurable objective goal. This was discussed and validated with the DPCS and the administrator.

Observed in Record Review. In 2 of 9 patient records reviewed, Nurse surveyor noted the written aide care plan did not contain written instructions for the hospice aide. In RR7 and RR8 the patient were on a blood thinner, however, on review of the aide plan of care, there were no instructions for bleeding precautions. Additionally, in RR7 the aide care plan contained instructions to shave patient but did not give further clarification regarding use of razor or electric razor for safety. This was reviewed and validated with the Director of Patient Care Services.

Observed in HR File Review. In 1 of 10 HR files reviewed, Nurse surveyor noted the organization did not have documentation of the assessment of skills and competency for contracted staff. Example in HR#8, for the medical director, there was no documentation to validate competency had been evaluated for his position. This was discussed and validated with administrator.

Observed in Patient Home. In 1 of 13 patient records reviewed, Surveyor noted the medication list in the record was inaccurate. Examples include, in HV1 the patient medication list did not match medications in the home; patient taking albuterol inhaler, sleeping pills containing Benadryl, and ibuprofen daily not on organization medication list. Patient caregiver reports these medications not new for the patient. This was discussed and validated with the Director of Patient Care Services.