Every finding on record at Loving Rainbow Hospice

Upon personnel record review, 1 of 14 (Personnel # 6) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement. ·Appropriate and safe techniques in personal hygiene and grooming that include-- ·(B) Sponge, tub, and shower bath ·(C) Shampoo, sink, tub, and bed The other subject areas in this section may be evaluated through written examination, oral examination or after observation of a Hospice Aide with a patient. Personnel #6 competency included "tub/shower" with evaluation method of "V" for verbal also included "shampoo-tub, shower, bath, sink" does not include shampoo in "bed".

Upon patient record review, 1 of 5 (Patient #3) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #3 First name misspelled on all agency-generated clinical records. This was observed and verified with the patient during home visit and medication reconciliation. The medication bottles spelled first name as "Sona" while all agency documents spelled first name as "Sonia".

Upon patient record review, 5 of 5 (Patient #1,2,3,4,5) did not have evidence in the patient record that the interdisciplinary group, as part of the review of the plan of care, determines the ability of the patient and/or family to safely self-administer drugs and biologicals to the patient in his or her home. If the patient and/or family are not capable of safely administering drugs and biologicals in the home, the hospice must address this issue in the patient's plan of care. Patients #1-5 had evidence of the admission nurse assessment of "can patient safely administer own medications?" nurse typed "yes". However; nurse documented Neuro/Mental status as "confused" in Comprehensive admission assessment for patients 1-4. The MSW documents patients 1-5 as "Alert and oriented ". There is no evidence of IDG discussion.