Every finding on record at Mission Health Care Services

Observed in Record Review. In 6 of 13 patient records reviewed, the organization failed to respect the patient's rights to participate in decisions about their care. In HOSRRHV #1, HOSRRNHV #1, HOSRRNHV #2, HOSRRNHV #4, and HOSRRNHV #7 the patient's had a signed NOMNC in their admission documents. This was reviewed and validated with the Administrator and interim DCPS.

Observed in Record Review. In 12 of 13 patient records reviewed, the organization failed to respect the patient's right to participate in decisions about their care, treatment or services. In HOSRRHV #1 the non covered items form did not have a date it was requested nor a date when it was given to the patient. In HOSRRHV #2 the hospice surveyor observed that neither the Admission Consent nor the Election of Benefits included language where the patient could request a copy of non covered items from the organization. In HOSRRNHV #1, HOSRRNHV #2, HOSRRNHV #3, HOSRRNHV #4, HOSRRNHV #5 ,HOSRRNHV #6, HOSRRNHV #7, HOSRRDC #1, HOSRRDC #2 , HOSRRDC #2, and HOSRRBRV #1 the surveyor observed that in the EOB the section on whether the patient or caregiver would like an addendum was left blank. Upon review of the charts there were no services, DME, or medications that should have been covered and were not. This was reviewed and validated with the Administrator and interim DCPS.

Observed in Record Review. In 13 of 13 patient records reviewed, the need for volunteer services was not assessed. In HOSRRHV #1, HOSRRHV #2, HOSRRNHV #1, HOSRRNHV #2, HOSRRNHV #3, HOSRRNHV #4, HOSRRNHV #5, HOSRRNHV #6, HOSRRNHV #6, HOSRRNHV #7, HOSRRNHV #8, HOSRRDC #1, HOSRRDC #2, HOSRRBRV #1, HOSRRBRV #2 the hospice nurse surveyor observed that the clinicians did not assess for the need of a volunteer. . In HOSRRHV #2 the patient had a diagnosis of ALS and a fall risk assessment was not completed by the nurse at SOC per the organizational policy Comprehensive Assessment. The organization failed to accurately measure the patient's target pain goal. In HOSRRNHV #5 the patient was in pain and there was a pain care plan but the Pain Assessment Policy states that the clinician will assess and document the patient's pain goal in the care plan. The nurse did not enter a pain goal in the assessment for this patient but the care plan stated that the patient's acceptable level of pain control was 2 out of 10. This was reviewed and validated with the Administrator and interim DCPS.

Observed in Record Review. In 4 of 13 patient records reviewed, the written plan of care was not based on the patient’s goal. In HOSRRHV #1, HOSRRNHV #4 , HOSRRNHV #6, and HOSRRBRV #1 the patient's were non verbal and an observational tool was used to assess for pain. The care plan for pain stated, Pain is at or below acceptable level as determined by the patient. The patient's were nonverbal so unable to give an acceptable level of pain. Additionally, the organization's Pain Assessment policy 2-032.1 stated if patient unable to communicate pain using a rating scale then the clinician will asses behavioral factors and include this in the assessment. This was reviewed and validated with the Administrator and the interim DCPS.

Observed in Record Review. In 11 of 13 patient records reviewed, the organization failed to plan the patients care. In HOSRRHV #1 the patient was on ASA 81 mg daily and the nurse did not include a care plan on bleeding precautions. This patient was also on Oxygen 2 liters via nasal cannula continuous and there was no care plan on oxygen safety. The nurse also assessed combativeness and constipation and there were no care plans entered addressing these issues. In HOSRRHV #2 the patient was assessed to be incontinent of bowel and had difficulty swallowing with a nutritional decline per CTI, and there were no nursing care plans addressing these issues. In HOSRRNHV #1 the patient was agitated and there was not a care plan addressing this. In HOSRRNHV #2 the patient had a diagnosis of cardiac and renal failure , dysphagia,, and a fall risk and there were no care plans entered into the POC addressing these issues. In HOSRRNHV #3 the patient was on 81 mg of ASA daily and there was no care plan addressing bleeding precautions in the POC. Additionally the pain goal in the care plan states 3 /10 or less this was never assessed in the nursing assessment. This patient also had severe abdominal pain at admission and was treated with oxycodone per IDT and there was no care plan addressing this. In IDT the nurse documented that the patient had a diagnosis of COPD and was currently smoking and this was also not addressed in the care plans in the POC. In HOSRRNHV #4 the patient was assessed for agitation and on Lorazepam and Haloperidol and there was no care plan addressing this issue. Additionally, this patient was on ASA 81 mg and no bleeding precaution care plan was entered and the patient was also a fall. rsisk and no fall risk care plan was entered into the POC. In HOSRRNHV #5 the patient was a started on oxygen 7 days after admission no oxygen care plan entered. Pt also had issues with inability to swallow and there was no care plan entered to address this. In HOSRRNHV #6 the patient was started on oxygen and an oxygen safety care plan was not entered into the POC. In HOSRRBRV #1 the patient was assessed by RN as a fall risk and on Oxygen therapy. There were no care plans entered in the POC on either fall or oxygen safety. In HOSRRHV #1 ,, HOSRRNHV #2 , HOSRRNHV #5, HOSRRNHV #6, HOSRRNHV #7, and HOSRRDC #1 the SOC POC had frequencies for both MSW and Chaplain, e.g. one time per month, but there were no care plans entered for either discipline. In HOSRRNHV #1, HOSRRNHV #2, and HOSRRBRV #1 there was a frequency for MSW monthly and prn in the POC and there were no care plans entered. In HOSRRNHV #3, HOSRRNHV #4 , and HOSRRDC #2 the chaplain had a frequency of one time per month and there were no care plans entered into the POC.In HOSRRNHV #7 there were no RN care plans established at SOC with a nursing frequency order of one time per week for 90 ats, The first care plans noted 28 day later in IDT meeting. In HOSRRHV #2, HOSRRNHV #3, HOSRRNHV #4, and HOSRRNHV #5 the patient had a foley catheter and the plan of care did not include orders for the size of the catheter, the balloon size, and the type and amount of fluid used to fill. In HOSRRNHV #2 the patient had wounds to her right leg, right inner groin and sacrum and there were no wound care orders found. Additionally, in this patient there was an order from the provider instructing the nurse to Initiate Oxygen therapy and titrate up as needed for comfort. No parameters given and the patient is currently on 4 liters of oxygen continuous. In HOSRRDC #2 the patient had a suprapubic catheter, no orders found for the catheter size, balloon size and fill, and the frequency of changes. In HOSRRNHV #4 and HOSRRBRV #1 there were duplicate medications entered for pain with no clear indication when the patient was to take one over the other, The patient was on Tylenol 325 mg 2 tablets every 6 hours for pain, Oxycodone 5 mg tablet every 4 hours for pain, and Morphine Sulfate 0.25 ml every 3 hours for pain. Additionally these patient's also had an order for Venelex External Ointment with no clear indication of where the put the topical agent, the medication list stated to affected areas. In HOSRRNHV #3 the patient had duplicate orders for pain medications without clear indication when to take one over the other. The patient had orders for Lorazepam 0.20 ml every 4 hours for pain, Oxycodone 0.25 ml every 4 hours for pain, and Tylenol extra strength 500 mg every 6 hours for pain. In HOSRRNHV #7 the patient had orders for Polymyxin B-Trimethoprim solution one in affected eye, no documentation which eye and also Voltaren external ointment to apply to affected areas no specific documentation as to which area to apply it to. This was reviewed and validated with the Administrator interim DCPS.

Observed in Record Review. In 1 of 13 patient records reviewed, there were missed visits, but the physician was not notified.  In HOSRRHV #1 the patient had a missed visit in January and the provider was sent a fax with no reason entered for the missed visit or who submitted the missed visit. Per the organization's Missed Visit policy 2-.087.1 the physician should have been notified of the reason for the missed visit as well as there should have been documentation as to who completed the missed visit and if any follow up was required. This was reviewed and validated with the Administrator and interim DPCS.

Observed in Record Review. In 1 of 2 patient records reviewed, the organization failed to send out bereavement mailings at designated time frames. In HOSRRBRV #1 the care giver did not receive their three month mailing/contact per the Bereavement Services Policy -010.1. This was reviewed and validated with the Administrator.

Observed in Record Review. In 5 of 13 patient records reviewed, the organization failed to prepare written patient care instructions for the hospice aide. In HOSRRHV #1 the patient was on aspirin 81 mg daily, oxygen 2 liters via nasal cannula continuous, and was getting wound care to her left heel. The aide care plan did not include bleeding precautions. Additionally, the aide care plan did not give instructions as to what the aide should do with oxygen during the shower as well as what to do with the dressing if it was dislodged during the shower. In HOSRRNHV #2, HOSRRNHV #6, and HOSRRBRV #1 the patient was a fall risk and on Oxygen 2 liters via nasal cannula continuous and no safety precautions documented in the aide care plan. Additionally, the aide was not given specific instructions of what to do with the oxygen when giving the patient a bath. In HOSRRDC#1 the patient was deemed a fall risk and this was not entered in the precautions for the Home Health Aide. This was reviewed and validated with the Administrator and interim DCPS.

Observed in Patient Home. In 1 of 1 home visits conducted, where a home health aide provided care the surveyor observed that the home health aide failed to follow the aiide care plan. In HHRRHV #1 the home health aide care plan stated that the home health aide would provide assistance with dressing, comb hair, fort care, shampoo hair, skin care, oral hygiene, and make bed with each visit. The home health aide did not offer or provide any of these services. This was reviewed and validated with the interim DPCS.

Observed in HR File Review. In 1 of 7 HR files reviewed, for hospice the organization failed to ensure staff competence was assessed and documented once every three years or more frequently as required by policy. On review of HosHR#4 for the Medical Director there was no documentation of a competency assessment noted in the HR file. This observation was reviewed with the HR director and Administrator.

Observed in Patient Home. In 1 of 1 home visits conducted, where medication reconciliation was done by the surveyor it was observed that the medication list in the home did not reconcile with the list from the organization. In HOSRRHV #2 the patient had the following medications in the home which were not on the organization's medication list: Cranberry Concentrate with C 30,000 mg 1 tablet daily, Chlorphenoxamine Maleate 4 mg one tablet every day, Probiotic 10 20 Billion units 1 by mouth daily, Aleve 220 mg 1 every 12 hours, and Imodium AD 2 mg one tablet by mouth every day. This was reviewed and validated with the Interim DPCS.

Observed in Record Review. In 2 of 2 patient records reviewed, where the patient's had a live discharge it was observed by the Hospice surveyor that the organization failed to provide a discharge summary to the receiving hospice agency or community provider. In HOSRRDCV #1 the community provider was not provided a discharge summary and HOSRRDC #2 the patient was transferred to another Hospice and they too did not receive a discharge summary per the organization;'s Transfer Information Policy 2-070.1 and Discharge from Hospice Program Policy 2-071.. This was reviewed and validated with the Administrator and interim DCPS.

Observed in Record Review. In 3 of 3 patient records reviewed, for active hospice patients the nurse surveyor noted that the goals were not measurable. For example, “Patient’s depression will be managed”, and “Patient’s blood sugar will be managed within acceptable levels”. Additionally, there were no short-term goals at start of care to address issues of immediate needs such as understanding medication management, symptom management, pain management, mobility or safety, the timeframe for completion on most was at death/discharge. Findings were verified by the Hospice Director.

Observed in Patient Home. In 1 of 3 home visits conducted, it was observed by the nurse surveyor that the nurse did not clean her equipment per the agency’s “Bag Technique Procedure”. For HOSHV#1/RR#1 the nurse cleaned her equipment (BP cuff, stethoscope, thermometer) all in her one hand. She then put them straight into her nursing bag with her dirty gloves on. The equipment was cleaned with an antiseptic wipe that has a dry time. Finding was verified by the Hospice Director. Observed in Patient Home. In 1 of 3 home visits conducted, it was noted by the nurse surveyor that for HOSHV#1/RR#1 the skilled nurse had numerous breaks in hand hygiene, per the agency’s “Hand Hygiene Procedure”, she did not change gloves between touching the patient and touching other items, when she did she change gloves she did not consistently hand sanitize prior to putting clean gloves on. The skilled nurse cleaned her equipment holding all items in her hand, then she put them in her nursing bag, still with the dirty gloves on. She then completed a medication reconciliation without hand sanitizing before or after touching all of the medication bottles. The Hospice Director was present during the home visits and also observed the breaks in technique per agency policy.

Observed in Record Review. In 2 of 2 patient records reviewed, of active patients with a hospice aide, it was noted by the nurse surveyor that for HOSHV#1/RR#1 and HOSHV#2/RR#2 the hospice aide care plan did not include parameters/situations of when the hospice aide should notify the registered nurse. Additionally, for HOSHV#1/RR#1 the patient was on oxygen and the care plan did not address the hospice aide’s responsibility for the oxygen if the patient was using it at the time of the bath. All findings were verified by the Director of Hospice.

Observed in Record Review. In 1 of 2 patient records reviewed, for patients with a hospice aide, t was noted by the nurse surveyor that for HOSHV#2/RR#2, Hospice Aide Supervisory visits were not documented the required every fourteen days. Two times they were three days late, one time they were one day late. Findings were verified with the Director of the Hospice Program.

Observed in Record Review. In 2 of 3 patient records reviewed, with a live discharge, the nurse surveyor noted that for DC#1/RR#4 and DC#4/RR#7 that the attending physician was not notified of the availability of a discharge summary. Additionally, a discharge summary was not documented at the time of discharge. Finding was verified by the Director of Hospice.