Every finding on record at New Horizon Hospice, Inc.

Observed in Record Review. In 10 of 10 patient records reviewed, During HV#1, HV#2, HV#3, RR#1, RR#2, RR#3, RR#4, RR#5, RR#6 and RR#7 it was noted the MSW and SC interventions on the POC were entered by the RN. There was lack of documentation of input or collaboration from the MSW or SC when the interventions were added to the POC. In additions, updates to the POCs for the MSW and SC are documented by the RN for RR#4 and RR#5 without documentation of input from the MSW. Initial SC interventions added to HV#1, HV#2 and HV#3 POC by the RN This was discussed with the organization leadership.

Observed in Record Review. In 1 of 10 patient records reviewed, During HV#3 record review it was noted the frequency of visits for the MSW and SC were MSW: 1 One-time then PRN - for emotional or psychological issues, and SC: 1 One-time then PRN - for spiritual concerns. The order lacked the number of PRN visits per certification from August 2023 to the present certification in October 2024. This was discussed with the organization leadership.

Observed in Record Review. In 1 of 10 patient records reviewed, During RR#2 it was noted an order for a oxygen concentrator on the medication profile, and documented on RN comprehensive notes the use of oxygen therapy at 3L/min PRN. The POC lacked an order for oxygen therapy use and liter flow. This was discussed with the organization leadership.

Observed in Record Review. In 1 of 10 patient records reviewed, During HV#3 record review it was noted the MSW did not follow the POC. The MSW did an initial visit during the comprehensive assessment in August 2023 with a frequency order of 1x then PRN for emotional or psychosocial issue. The MSW made phone call visits to the patient residence 12 times since the comprehensive assessment without updating the IDG and POC to reflect the type and frequency of visits. The Spiritual Counselor (SC) visited the patient once a certification period since the initial SC assessment in August 2023 with an ordered frequency of 1x plus PRN for spiritual needs. The IDG and POC were not updated to reflect the frequency of visits provided. This was discussed with the organization leadership.

Observed in Patient Home. In 2 of 3 home visits conducted, During HV#1 and HV#3 it was noted the SNs did not adhere to the manufacturer guidelines for disinfecting medical equipment. Wet contact time of the disinfectant product of 4 minutes for the product used during HV#1 and 2 minutes for the product used during HV#3 was not adhered to before returning the equipment to their bags. The equipment included pulse oximetry device, thermometer, BP equipment and stethoscope. This was discussed with the organization leadership. Observed in Patient Home. In 1 of 3 home visits conducted, During HV#1 it was noted the SN did not follow the organization policy on hand hygiene. After examining the patient back and buttock area, the SN removed her gloves and did not disinfect her hands before donning another pair of gloves. This was discussed with the organization leadership.

Observed in Record Review. In 1 of 2 patient records reviewed, who were discharged alive. During Live D/C RR#2 it was noted the patient was hospitalized. There was lack of documentation that the discharge summary was sent to the receiving hospital where the patient was admitted. This was discussed with the organization leadership.

Observed in Record Review. In 9 of 11 patient records reviewed, appropriateness of the plans of care, the hospice surveyor noted that the plans of care did not include measurable outcomes anticipated from implementing and coordinating the plan of care . For example For example RR #1 patient will be comfortable and remain free of injury. RR# 2 patient ADL needs are met to an optimal level , RR# 3 Patient/Family/PCG will express feeling of grief/loss HOSV# 3 Pt will verbalize and/or express decreased episodes of chest pain. There were no measurable out comes included in the plans of care for any of the identified goals HOSV #1, 2 and RR#6,7,8.This was discussed with the Administrator.

Observed in Record Review. In 6 of 11 patient records reviewed, The organization did not provide the patient with services according to their individualized plan of care. The surveyor noted that in HOSV#1, HOSV#2, HOSV#3 , RR #1, RR#2, and RR# 3 the Medical Social worker ( MSW) and the Spiritual Counselor (SC) documented that they visited the patient every month. According the Plan of care (POC) frequency (SC: 1 One-time then PRN -Evaluation only and (MSW: 1 One-time then PRN - Evaluation only) . This was discussed with Administrator.

Observed in Record Review. In 1 of 7 patient records reviewed, during RR#2 the Nurse Surveyor noted that the Licensed Vocational Nurse (LVN) did not notify RN case manager about a significant change in patient’s condition. On 5 consecutive visit note the LVN documented that patient having generalized body pain level of 7/10 and taking Norco . Lungs auscultated bilaterally with diminished sounds. Patient has moderate dyspnea upon minimal exertion and offered 02 tx at 2 lpm but declined . This was discussed with the Administrator.

Observed in Record Review. In 2 of 2 patient records reviewed, the nurse surveyor noted that there was no evidence that Home Health Aide (HHA)was supervised in RR# 3 for a period of more than 17 weeks. Also in RR #4 no evidence of HHA supervision completed for 24 weeks. This was discussed with the Administrator.

Observed in Record Review. In 11 of 11 patient records reviewed, the surveyor noted that the Medical Director reviewed clinical information and signed the initial certificate of terminal illness (CTI) on a timely manner but The CTI did not consider all of the required elements. For example: During record review of HV# 1, HV# 2, HV #3, RR #1, RR#2, RR# 3, RR#, RR# 5 and RR#6,7,8. The Hospice Surveyor observed in the CTI under Physician Narrative that the written certification Narrative was documented as followed in all the records: Patient telehealth by Dr ... for Face to face and recommended patient eligible for hospice admission. This was discussed with the Administrator.