Every finding on record at Missouri Hospice Care, LLC

Observed in Patient Home. In 3 of 3 home visits conducted, the organization had not provided the patient/family with written information about its policies on advance directives, including a description of any state law concerning advance directives. In review of the home folder for RRHV #1 although the organization had included information on advance directives in the home folder they had not provided a description of Missouri State law for example, information on the Missouri's Advance Health Care Directives Registry. This also was observed for RRHV #2 and RRHV #3. This was discussed with the Clinical Supervisor.

Observed in Record Review. In 1 of 10 patient records reviewed, the initial comprehensive assessment was not completed within five calendar days of the patient electing the hospice benefit. In review of the medical record for RRNHV #4 the spiritual assessment and the bereavement assessment were conducted on the 6th day following the election of the hospice benefit. This was discussed with the Clinical Director.

Observed in Patient Home. In 2 of 2 home visits conducted, with nursing staff, the organization failed to assess for potential medication-related problems in accordance with their policy. For RRHV #1 the RN completed the skilled nursing visit without reconciling the medications in accordance with the organization's policy #7003 Medication Management Policy which states; the patient's medications are reviewed and assessed during each skilled visit. The RN reported that she reviews the medications every few weeks and at the time of re-certification. Also, for RRHV #2 although the RN did provide an updated medication list and asked the patient's husband who was the primary caregiver if there were any changes or problems with medications the RN did not reconcile all of the patient's 22 medications in accordance with the organization's policy. This was discussed with the Clinical Director.

Observed in Record Review. In 10 of 10 patient records reviewed, the written plan of care did not include measurable goals and the time frames and services required to meet those goals. For example; in review of the medical record for RRHV #2 the plan of care included a problem of pain with a goal that pt/pcg verbalizes pain is controlled within their desired comfort level within 48 hours of intervention.. The goals did not have measurable outcomes such as a pain rating that the patient/family would like to achieve. The surveyor noted the same problem and goals were written in the medical records for RRHV #1, RRHV #3, RRNHV #1, RRNHV #2, RRNHV #3, RRNHV #4, RRNHV #5, RRNHV #6 and RRNHV #7 and the plans of care were not individualized according for each patient. This was verified with the Clinical Director.

Observed in Record Review. In 1 of 10 patient records reviewed, the organization did not provide care, treatment or services according to the patient's individualized plan of care. In review of the medical record for RRHV #1 the spiritual counselor did not visit the patient once a month in accordance with the plan of care. The surveyor noted that during the second and third month of care there was documentation of a telephone call to schedule a visit however there was no answer and no evidence of follow up by the spiritual counselor to schedule and complete the visits as planned. This was discussed with the Clinical Director.

Observed in Patient Home. In 1 of 3 home visits conducted, staff failed to follow the organization's policy # 4006 Hand Hygiene. For RRHV #2 the RN failed to perform hand hygiene upon entering the home and having contact with the patient. Additionally, the surveyor observed the RN then perform hand hygiene, glove and the perform the assessment of the patient however failed to perform hand hygiene after removing gloves. Finally, the surveyor observed the RN perform hand hygiene, glove and then inspect the patient's buttocks, then remove gloves and proceed with visit by picking up his cell phone, putting away medical equipment without performing hand hygiene. This was discussed with the Clinical Director.

Observed in HR File Review. In 2 of 2 HR files reviewed, for volunteers, the organization had not documented volunteer orientation and training. In review of the personnel files for HR #1 and HR #2 for hospice volunteers there was no evidence of orientation to the organization or that the volunteers had completed the volunteer training program as required. This was validated with the Clinical Director.

Observed in Document Review. The hospice had not documented its efforts to recruit and retain volunteers. In review of the Volunteer Program and in discussion with the Volunteer Coordinator there was no evidence that the hospice had documented its recruitment and retention efforts.

Observed in HR File Review. In 1 of 7 HR files reviewed, the organization had not defined the competencies it requires of social workers. In review of the personnel file for HR #3 who was a social worker the surveyor noted that the competencies that were assessed were related to infection control, bag technique, security awareness, ergonomics for health care workers however there were no competencies specific to the role of the social worker such as conducting a psychosocial assessment of clients to determine their psychological, social, emotional, and spiritual needs. This was validated with the Clinical Director.

Observed in Record Review. In 1 of 1 home visits conducted, to patient's who resided in a Skilled Nursing Facility (SNF), the organization had not provided the SNF with required information and documents in accordance with the organization's policy #9122A Provding Hospice Car for Patient/Resident of Contracted Facility. In review of the facility record for RRHV #3 who resided in a SNF the record did not contain the hospice medication list, hospice physician orders and a complete plan of care since the patient's admission 14 months ago. This was validated by the hospice social worker and discussed with the Clinical Director.

Observed in Individual Tracer. In 5 of 13 , The hospice nurse surveyor noted (HV#1) that the spiritual assessment was not completed. The surveyor noted that the chaplain contacted the patient within the first five days but failed to arrange for a visit. There was no indication that the patient had refused the visit. This was corrected on site, a visit was arranged and confirmed with the clinical director. Also, on (HV#2) and (HV#3) the surveyor noted that the bereavement risk assessments were not completed. The surveyor noted that the assessment in the medical record including several components; however, they were not completed. IN (HV#3) the chaplain documented that the bereavement risk was completed with the patient and not the potential bereaved, and there was no indication that an attempt was made to contact the caregiver/family member. There was no bereavement assessment completed for (ARR#5), it stated that the daughter was not available and no further attempt was made to contact her to complete the assessment, since early October. This was confirmed with the quality manager.

Observed in Individual Tracer. The hospice nurse surveyor noted (HV#2) that the patient was readmitted in March; however there was no evidence that a bereavement assessment was completed within 5 days of the readmission. Also, the surveyor noted that there was no evidence that (HV#3) a bereavement assessment was completed when the patient was re-admitted in September. In (ARR#4) there was no evidence that a bereavement risk assessment was completed for the patient's daughter or attempt to contact the daughter to complete the initial assessment. This was confirmed with the clinical director.

Observed in Record Review. The hospice nurse surveyor noted (ARR#6) that the comprehensive nursing assessment was not completed. The surveyor noted that the skin assessment did not include a Braden scale, as required. Also, the nurse identified that the patient had constipation; however the severity was not assessed. also the nurse noted in a subsequent visit that the patient had gas pains; however, a comprehensive pain assessment was not completed to assess the severity of the pain. In another note the nurse indicated that the patient had left shoulder and elbow pain; however, the severity was not assessed.

Observed in Individual Tracer. In 9 of 13 patient records reviewed, The hospice nurse surveyor noted (HV#1) that the written plan of care did not include outcome measures and time frames that reflected the patient and family goals. The surveyor noted (HV#3), (ARR#1,) (ARR#2), (ARR#4), (ARR#5), (ARR#6), (DRR#1) and (DRR#2) that the goals were vague, for example optimal bowel function, pain controlled at desired level, reduced episodes of chest discomfort, optimal level of anticoagulation, and anxiety minimized, with no time frames or expected outcomes for achieving goals. This was confirmed with the clinical director.

Observed in Individual Tracer. The hospice nurse surveyor noted (HV#1) that the aide trimmed the patient's toenails; however the plan of care did not specify that nails could be trimmed and simply stated nail care. The plan of care orders indicated that the skilled nurse had orders to cut nails and not the aide.

Observed in HR File Review. In 3 of 11 HR files reviewed, The hospice nurse surveyor noted during the competency session and personnel file review that there was no evidence that a competency assessment was completed for the medical director and the alternate medical director when they were hired or since. There was only documentation of online education and no verification of skills by another physician. Also, there was no evidence that the social worker competency was completed by another social worker on hire in May, or since. This was confirmed with the administrator.

Observed in Individual Tracer. In 13 of 13 patient records reviewed, The hospice nurse surveyor noted (HV#1) that the bereavement risk assessment was not documented. The surveyor noted that the form in the electronic medical record was blank. Also, the bereavement risk assessment was not documented in the record for (ARR#3), there was only a notation that stated the risk was low. The surveyor confirmed with the executive director that the chaplains use a paper document to determine the risk level; however the paper document iwa not retained and added to the medical record.

Observed in Individual Tracer. In 3 of 3 home visits conducted, The hospice nurse surveyor noted (HV#1) that the interdisciplinary team meeting notes were signed by the staff; however none of the signatures were dated. The surveyor confirmed that the signatures were not obtained during the meetings. The surveyor confirmed with the clinical director that this was not the practice and that none of the meeting notes were dated when signed.

Observed in Record Review. The hospice nurse surveyor noted (DRR#2) that there was no evidence that the organization provided the receiving agency with a copy of the patient's discharge summary or summary of the patient's care when the patient was discharge to the hospital. This was confirmed with the clinical director.

Observed in Individual Tracer. The hospice nurse surveyor noted (HV#3) that the patient indicated that she had two back-up oxygen tanks that she was storing in the back of a closed closet (not ventilated); however there was no evidence in the medical record that she was educated about the safe storage of oxygen tanks. This was confirmed with the clinical director.

Observed in Individual Tracer. The hospice nurse surveyor noted (HV#2) that the patient resided in a nursing facility and was readmitted to hospice in March. The surveyor noted that the collaborative care plan found in the patient's facility medical record was blank and there was no evidence that the hospice care plan was provided to the staff. Also, the plan of care did not indicate what staff was to provide care and treatments. The hospice nurse was unable to locate the certification statement or election form for the current admission. in the facility record. This was confirmed with the clinical director.

Observed in HR File Review. In 3 of 11 HR files reviewed, The hospice nurse surveyor noted that the license verification with the primary source was not completed at the time of renewal. The surveyor noted that the license of the RN, DON, and LPN1 were not validated when they renewed in April and were not verified until August (4 months later). This was confirmed with the administrator.