Every finding on record at Luxe Hospice, Inc.

Observed in Record Review. In 1 of 9 patient records reviewed, the organization did not establish individualized and measurable goals for the patient. For example, in RRBR #1 benefit period 1 the goal, be able to cope with changes and SC will be available whenever needed. The goal did not specify what changes the patient will be able to cope with and how it will be measured. The SC goal was not a measurable goal for the patient/family/caregiver. This was reviewed with the Administrator and the CEO. Observed in Record Review. In 1 of 9 patient records reviewed, the organization did not establish an appropriate length of time for the goals. In benefit period 1 RRBR #1 there were over 50% of the goals that went beyond benefit period #1. For example, Respiratory-patient will verbalize and or express decreased episodes of SOB at rest, patient will remain in comfortable level during care; sleep: patient's agitation/restlessness will be resolved with current medication order; GI: patient/PCG will verbalize having elimination needs met at an acceptable level. Neurological/Mental: patient's agitation/restlessness will be resolved with current medication order. All goals had a target date that went into benefit period #2. This was reviewed with the Administrator and the CEO. Observed in Record Review. In 2 of 9 patient records reviewed, the organization did not establish appropriate timeframes for the pain goals. For example, in benefit period #1, RRBR #1 the pain goal, patient will remain in comfortable level during care; target date: exceeded the end of the episode date. In RRHV #1 Benefit period 3 the pain goal is extended to 7 weeks from the recertification date. The pain goal is too long of a duration for pain control to ensure comfort of the patient. This was reviewed with the Administrator and the CEO.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization did not differentiate PRN medication use. For example, in RRHV #1 the patient is prescribed Acetaminophen 500 milligrams 2 tablets (1000 milligrams total) oral every 6 hours as needed for pain and Morphine Sulfate Solution 100 milligrams/5 milliliters 0.25 milliliters sublingual every 2 hours as needed for pain/shortness of breath. The organization did not provide specific instructions as to when to take which medication. This was reviewed with the Administrator and the CEO.

Observed in Record Review. In 1 of 9 patient records reviewed, the organization did not follow the plan of care. For example, in benefit period 3, RRHV #1 the hospice aide did not make the last visit of the episode. Another example, in benefit period #3 during the first week of the episode the Skilled Nurse missed two visits. In review of the clinical record there is no documentation of missed visits and or the Physician being notified of the missed visits. The organization was not aware of the missed visits until the missed visit were identified by the Surveyor. This was validated and reviewed with the Alternate Administrator and the LVN/LPN.

Observed in Emergency Management Session. During the Emergency Management Session and document review the surveyor noted that the Emergency Operations Plan did not describe how the organization would inform state and local officials of any on-duty staff they are unable to contact. This was confirmed with the Coordinator and Administrator Designee present.

Observed in Emergency Management Session. During review of Emergency Management documentation and discussion with the Administrator Designee the surveyor noted that the organization had not determined what its role would be, if any, in the community response plan. This was confirmed with the Administrator designee.

Observed in Patient Home. In 1 of 3 home visits conducted, the surveyor noted that the organization failed to assesses for potential medication-related problems, including adverse effects, drug reactions, significant side effects, and significant drug interactions, including ineffective drug therapy, duplicate drug therapy, and noncompliance with drug therapy. For example, the hospice nurse failed to conduct an effective medication assessment. She asked if there had been any medication changes, but did not check the medications.

Observed in Patient Home. In 3 of 3 home visits conducted, the surveyor noted that the nurse did not implement infection prevention and control activities . For example, during HV#1 and HV#2 the nurse donned gloves at the beginning of the visit and used these gloves throughout the visit without changing the gloves when she accessed items in the nursing bag, prior to or after direct contact with the patient and the environment or when she used her phone. HV#3 the nurse changed gloves one time during the visit, but entered the nursing bag and used her cell phone while wearing the gloves after working directly with the patient. The organization's Nursing Bag policy required hand hygiene to be performed prior to entering the bag and the Hand Hygiene policy required hand hygiene before and after direct contact with the patient. This was confirmed with the administrator designee and coordinator.

Observed in HR File Review. In 2 of 3 HR files reviewed, with staff employed with the organization over 3 years, the surveyor noted that staff competence was not assessed and documented once every three years, or more frequently. For example, there was no evidence that the MSW and Spiritual Counselor/Bereavement Coordinator/Volunteer Coordinator had competencies documented every 3 years. This was confirmed with the Administrator Designee present.