Every finding on record at North Valley Hospice Inc.

Observed in Patient Home. In 1 of 3 home visits conducted, it was noted by the nurse surveyor that the nurse failed to follow acceptable practice when performing wound care. On RRHV#3, the registered nurse opened and placed the clean dressings to be applied over the patient’s wound on the dirty barrier where his used equipment was placed. Finding discussed with the Owner/CEO and the Director of Patient Care Services.

Observed in Record Review. In 1 of 6 patient records reviewed, for active patients, it was noted by the nurse surveyor that the hospice aide care plan did not contain all the necessary or current information. For RRHV#3, the patient had coccyx wound with a dressing, however there was not anything on the Hospice Aide care plan regarding the Hospice Aide’s responsibility or what she should report regarding the wound. Findings were discussed with the Director of Patient Care Services.

Observed in Record Review. In 1 of 6 patient records reviewed, for active patents, it was noted by the nurse surveyor that Hospice Aide Supervisory visits were not documented the required every fourteen days per regulation. For RRHV#3, there were no documented Hospice Aide Supervisory visits for twenty days. Findings were verified with the Director of Patient Care Services.

Observed in Patient Home. In 1 of 3 home visits conducted, it was noted by the surveyor that the medication profile was inaccurate. During RRHV#3, when asked what the patient takes for pain, the patient handed the nurse a bottle of Bayer Aspirin with Caffeine, 500mg. This medication was not noted on the mediation profile. Findings were reviewed with the Owner/CEO and the Director of Patient Care Services.

Observed in Individual Tracer. In 3 of 3 home visits conducted, HV1, HV2, HV3 during the home visit and review of the current plan of care, the surveyor noted the written plan of care did not show evidence it was based on the patient’s goals and the time frames, settings, and services required to meet those goals. For example, HV1, MSW goal stated understanding of hospice program and available resources:, however no outcome or time frame was documented; a second goal: patient will have optimum level of oxygen during care. There were multiple goals on POC with the goal to be achieved within the next 14 days. HV2, the MSW goal lacks coping skills related to loss of self worth but did not include a measurable outcome to demonstrate achieving the goal; HV3, the timeframes for goals for ADL, Mobility, Sleep, Skin (including pressure ulcer goal) were all identified as the end of the benefit period. This was validated by the Administrator/DPCS.

Observed in Individual Tracer. In 3 of 5 patient records reviewed, HV1, HV2, HV3, during the home visits and record review, the surveyor noted the organization did not show evidence the plan of care revisions were based on information from updates to the patient’s comprehensive assessment and addressed the patient’s progress toward goals and outcomes. For example HV1, HV2, HV3 there was no documentation regarding the progress towards the goals identified in the plan of care or in the IDG notes. The electronic software only indicated if the goal was controlled or pending. This was not compliant with the organization's Ongoing Comprehensive Assessment Policy # 2-031.2 which states progress towards hospice goals and patient needs and problems are assessed at each visit and the Interdisciplinary Meeting policy # 2-050.2 #6 that states it will note changes, response to treatment and progress toward targeted outcomes..... This was validated by the DPCS and Office Manager.

Observed in Data Session. During the data session with the Administrator/DPCS and Office Manager, the surveyor noted the organization had not shown evidence it had a process in place to use the data collected to monitor the effectiveness and safety of services and the quality of care. The organization had a comprehensive QAPI /PI plan, but had not demonstrated it had executed any tracking or evaluation of data. The plan was to collect data monthly, review quarterly, however there was no evidence the information had been used to monitor effectiveness. For example, the leaders indicated the information was all in the electronic software, however when printed for discussion purpose, the information did not reflect detailed or understandable data collection. The organization was unable to demonstrate a process that it collected and tracked accurate data which allowed leaders to identify, prioritize and focus on key performance improvement opportunities. This was validated by the Administrator and Office Manager.

Observed in Individual Tracer. In 3 of 3 home visits conducted, HV1, HV2, HV3 during the home visits, the surveyor noted the organization failed to implement its infection prevention and control activities, to minimize, reduce, or eliminate the risk of infection. For example, HV1, HV2, HV3, the nurse failed to remove gloves and/or perform hand hygiene prior to accessing the nurse bag after direct contact with patient and cleaning equipment. This was not compliant with the organization's Bag Technique Policy 9-014.1: #5 states when visit is completed, ….. hands will be washed and equipment and supplies will be returned to the bag. # 6. Hands will be decontaminated prior to returning clean equipment to bag. This was validated by the Administrator/DPCS.

Observed in Document Review. During contract review, the surveyor noted the agreement with the Skilled Nursing Facility did not include the following item: A provision stating that the hospice will report all mistreatment, neglect, or verbal, mental, sexual, and physical abuse to the SNF, NF, or ICF/IID administrator within 24 hours of the hospice becoming aware of the alleged violation, including injuries of unknown source, and misappropriation of patient property by anyone unrelated to the hospice. This was validated by the office manager.