Every finding on record at Northern Illinois Hospice Association

Observed in Emergency Management Session. The organization has a written delegation of authority plan however it did not provide the individual(s) with the legal authorization to act on behalf of the organization for specified purposes and to carry out specific duties. This was discussed with the CEO.

Observed in Emergency Management Session. The organization had not developed a staffing plan for managing all staff and volunteers based on the settings and services provided to meet patient care needs during the duration of an emergency or disaster incident or during a patient surge. The plan did not include use of volunteer staffing such as staffing agencies, and those deployed as part of the disaster medical assistance teams. This was discussed with the CEO. Observed in Emergency Management Session. The organization did not have a staffing plan which addressed the management of all staff and volunteers as follows: reporting processes; roles and responsibilities for essential functions; integrating staffing agencies, volunteer staffing, or deployed medical assistance teams into assigned roles and responsibilities; verifying the identity and licensures of volunteer practitioners (such as nurses, physicians, physical therapists). This was discussed with the CEO

Observed in Record Review. In 1 of 19 patient records reviewed, the hospice’s interdisciplinary group had not completed the comprehensive assessment no later than five calendar days after the election of hospice care. In the chart for RRHV#1, the Spiritual Care assessment had not been completed until six days after the election. This was discussed with the Quality Director.

Observed in Record Review. In 4 of 19 patient records reviewed, the written plan of care was not based on the patient’s goals and the time frames required to meet those goals. In the chart for RRHV#3, the patient was admitted to hospice after a fall with injury, with a history of falls, yet the goal on the plan of care was that the patient would remain free from falls while on hospice. There was no short term goal related to education about fall risks and fall reduction interventions for this high risk problem. In the chart for RRNHV#9 for the patient who had been admitted after having been hospitalized for bowel obstruction and chronic constipation, the bowel management goal was not objectively measurable and did not have an appropriate time frame for achievement and read Patient will achieve and maintain regular bowel movements while on hospice services. Additionally, the patient was assessed to have a foley catheter, yet there was no goal on the plan of care related to management or care of the catheter. In the chart for RRNHV#8, the patient was admitted with pressure ulcers and was at risk for pressure ulcer development, yet there was no goal on the plan of care addressing this problem. In the chart for RRNHV#10, the anticipated goal achievement date had not been individualized to the patient's acute pain management needs. Patient will demonstrate use of methods to maintain comfort while on hospice services.. This was discussed with the Quality Director and/or the Quality RN assisting with record review.

Observed in Record Review. In 5 of 19 patient records reviewed, the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions, including treatment necessary to meet the patient’s needs. During RRHV#5, the RN drained the pleurex catheter and provided site care and a dressing to the pluerex site. There was no order for site care nor a dressing on the hospice plan of care. In the chart for RRHV#3, the patient was admitted with multiple wounds. The RN documented care to a stage three pressure ulcer during the admission visit. There were no orders for wound care on the plan of care. The patient was sent home from the hospital with NPO as the diet. The hospice plan of care did not address the patient's diet, yet documentation included an as tolerated diet was provided. Additionally, the plan of care for this patient was not updated to reflect the emergency respite stay, the return to routine level of care post-respite stay, nor was the plan of care revised to remove the oxygen which was not implemented when the patient moved primary residence post-respite stay. In the chart for RRNHV#9, the patient was found to have a Foley catheter upon the initial assessment, yet the plan of care did not include orders for a urinary catheter. In the chart for RRNHV#8, the patient was admitted with a documented stage 2 pressure ulcer, a dressing in place, and a documented pressure ulcer risk, yet the plan of care did not include any pressure ulcer reduction interventions. In the chart for RRNHV#11, the plan of care orders included oxygen equipment, yet no ordered liter flow or frequency. This was discussed with the Quality Director.

Observed in Record Review. In 1 of 19 patient records reviewed, the organization had not provided the patient with care according to the patient's individualized plan of care. In the chart for RRNHV#6, music therapy had been ordered during the initial comprehensive assessment. There was no documentation in the chart to indicate that any attempt had been made to provide a music therapy visit as of the date of the survey, approximately six weeks post-admission. This was discussed with the Quality Director.

Observed in Record Review. In 1 of 19 patient records reviewed, all disciplines that provide care, treatment or services to the patient had not collaborated in the care of the patient and coordinated their efforts to support the goals outlined in the plan of care. In the chart for RRNHV#10, the RN documented that the patient was at the emergency department for treatment and IV fluids. There was no indication the hospice physician was aware of the change in condition until the subsequent IDT note. This was discussed with the Quality RN assisting with record review.

Observed in Data Session. The organization's written infection prevention and control goals did not include the following: Limiting unprotected exposure to pathogens. The organization had an overall infection prevention goal, not broken out into the required elements as confirmed with the Quality Director. Observed in Data Session. The organization's written infection prevention and control goals did not include the following: Limiting the spread of infections associated with the use of medical equipment, devices, and supplies. The organization had an overall infection prevention goal, not broken out into the required elements as confirmed with the Quality Director. Observed in Data Session. The organization's written infection prevention and control goals did not include the following: Limiting the spread of infections associated with procedures. The organization had an overall infection prevention goal, not broken out into the required elements as confirmed with the Quality Director.

Observed in Record Review. In 1 of 19 patient records reviewed, the hospice had not conducted and documented a patient-specific comprehensive assessment including patient and family spiritual orientation, including their desire for the involvement of a religious group; spiritual concerns or needs identified by the patient or family, such as despair, suffering, guilt, and forgiveness. In the chart for RRNHV#8, there was no initial spiritual assessment found which included the required elements. The spiritual visits documented were routine follow up visit notes. This was discussed with the QA Nurse assisting with record review.

Observed in Record Review. In 1 of 19 patient records reviewed, the RN had not prepared appropriate instructions for the hospice aide. In the chart for RRNHV#6, the initial aide care plan included instructions to provide a shower to the patient who was bed-bound in a private residence. Also to provide for foley catheter care, yet the patient did not have an indwelling catheter. This was discussed with the QA Nurse assisting with record review.

Observed in Tracer Activities. The supervising nurse had not assessed the aide’s ability to demonstrate continued satisfactory performance in the following: creating successful interpersonal relationships with the patient and family. The organization's aide supervisory documentation form in the medical record did not include the required elements as confirmed with the Quality Director.

Observed in Record Review. In 3 of 19 patient records reviewed, the patient record did not include specific notes on care, treatment, or service. In the chart for RRHV#5, the nursing staff was providing site care and dressing changes to the patient's pleurex chest tube site every other day during the draining of the tube. There was no detail of cleansing solution, dressing nor securement device in the documentation. In the chart for RRHV#3, the RN documented that wound care was provided to a stage three pressure ulcer, yet the documentation did not include the cleansing solution used nor the actual dressing that was applied. In the chart for RRNHV#10, during a prn visit, the RN documented administration of morphine 0.75ml. There was no documentation of milligrams nor route of administration. Additionally, in another visit, a RN documented she administered an enema and suppository yet there was no documentation of what medications were given. This patient had documentation in the most recent IDT that she had been in the ED in the past week and received IV hydration. It was unclear in the documentation how the hospice became aware of the transfer and treatment. This was discussed with the Quality Nurse assisting with record review.

Observed in Record Review. In 1 of 1 patient records reviewed, in which a transfer occurred, when the care of the patient was transferred to another Medicare/Medicaid-certified facility, the hospice had not provide the receiving facility with a copy of the patient’s clinical record. In the chart for RRNHV#10, the RN documented she checked with the ED about the patient's presence for treatment, however there was no documentation that any information about the patient's care, treatment and services were provided to the receiving facility. This was discussed with the Quality RN assisting with record review.