Every finding on record at Oasis Haven Hospice

Observed in Patient Home. In 2 of 3 home visits conducted, a skilled nurse did not conduct an effective medication reconciliation in the home at visits RRHV#1 and RRHV#3 because the lists were missing. When asked to describe the medication reconciliation process after the visits, each nurse correctly stated that medication bottle labels are to be compared to the medication list. This RFI was reviewed with the Administrator, Administrator Designee, and Director of Patient Care Services.

Observed in Record Review. In 10 of 10 active patient records reviewed, comfort kit prn orders included Tylenol, Tramadol, MS, and MS IR. The Tramadol order did not provide a numeric pain range for which the medication should be used. For example, a pain rating of 4 to 6 on a scale of 1 to 10. This RFI was reviewed with the Administrator, Administrator Designee, and Director of Patient Care Services.

Observed in Record Review. In 10 of 10 active patient records reviewed, the comprehensive assessment was not updated every 15 days or less. For example, in interdisciplinary group meeting notes written by core team members there was no documentation of patient decline, progress towards desired outcomes and goals and plans for the following two weeks. This RFI was reviewed with the Administrator, Administrator Designee, and Director of Patient Care Services.

Observed in Record Review. In 5 of 10 active patient records reviewed, the certificate of terminal illness did not include subjective and objective information to support patient life expectancy of six months or less at recertification. For example, in records RRHV#2, RRNHV#1, RRNHV#3, RRNHV#4, and RRNHV#7 the PPS and KPS scores did not change and there was little subjective documentation to indicate decline in the previous benefit period. This RFI was reviewed with the Administrator, Administrator Designee, and Director of Patient Care Services.

Observed in HR File Review. In 1 of 10 HR files reviewed, During HR# 3's HR file it was noted the organization had not ensured it provided orientation to staff. For example: review of HR# 3's HR file revealed a blank orientation form. This was reviewed, discussed, and validated by the Director of Patient Care Services.

Observed in Record Review. In 5 of 11 patient records reviewed, During HV# 1, HV# 2, RR# 1, RR# 5 and RR# 6's patient records review it was noted the organization had not ensured the Interdisciplinary Group (IDG) meeting notes included documentation of the patient decline, revisions to the plans of care and goals. For example: review of RR# 5's patient record revealed RR# 5 was discharged due to extended prognosis. However, review of the IDG/updated plans of care 25 days and 11 days prior to the discharged revealed no documentation RR# 5 was improving and no longer eligible for hospice. Review of RR# 6's patient record revealed RR# 6 was discharged due to extended prognosis. However, review of the IDG/updated plan of care dated seven days prior to RR# 6's patient representative's signed Notice of Medicare Non-Coverage (NOMNC) and the IDG/updated plan of care dated seven days after RR# 6's patient representative signed the NOMNC revealed no documentation RR# 6 was no longer eligible for hospice. Review of RR# 1's patient record revealed a recertification with no documentation in the IDG/updated plan of care regarding recertification of RR# 1. Review of HV# 1's patient record revealed a recertification with no documentation in the IDG/updated plan of care regarding recertification of HV# 1. Review of HV# 2's plan of care revealed an order for Physical Therapy (PT) and a goal for PT services. Review of the IDG/updated plans of care dated after the PT was discharged revealed no documentation if the PT goal was met or that PT was discharged. This was reviewed, discussed, and validated by the Director of Patient Care Services.

Observed in HR File Review. In 1 of 1 HR files reviewed of Home Health Aides, During HR# 3's HR file it was noted the required home health aide (HHA) competencies were completed, but the documentation failed to confirm competencies completed with an actual patient or a qualified pseudo patient. For example: review of the HHA initial competency assessment revealed all competencies were validated verbally. This was reviewed, discussed, and validated by the Director of Patient Care Services.

Observed in Record Review. In 2 of 5 active patient records reviewed with Home Health Aide services, During RR# 1 and RR# 2's patient records review it was noted the organization had not ensure the home health aide (HHA) written patient care instructions were complete. For example: review of RR# 1's patient record revealed RR# 1 had a G-tube for enteral feeding. Review of the HHA written instructions included the task of a shower. Further review of the HHA written instructions revealed no directions regarding the G-tube. Review of RR# 2's patient record revealed RR# 2 had a wound with a dressing to the sacrum. Review of the HHA written instructions included a shower with no directions regarding the dressing. This was reviewed, discussed, and validated by the Director of Patient Care Services.

Observed in Record Review. In 4 of 7 active patient records reviewed, During HV# 1, HV# 2, and RR# 1's patient records review it was noted the organization had not ensured the patient records contained information that reflected the patient's care, treatment, or services. For example: review review of HV# 2's patient record revealed Home Health Aide (HHA) services two times a week. Further review of HV# 2's patient record revealed no documentation of a second weekly visit approximately 71 days prior to the surveyor review of the record. Review of HV# 1's patient record revealed a plan of care with HHA services two times a week. Further review of the patient record revealed the last documented HHA visit note was 13 days prior to the surveyor review of the record. Review of RR# 1's patient record revealed a plan of care with HHA services two times a week. Further review of the patient record revealed the last documented HHA visit note was 13 days prior to the surveyor review of the record. This was reviewed, discussed, and validated by the Director of Patient Care Services.

Observed in Record Review. In 2 of 7 active patient records reviewed, During HV# 2 and RR# 3's patient record it was noted the organization had not ensured all entries into the patient's record were authenticated. For example: review of HV# 2 and RR# 3's Initial Plans of Care revealed no signatures from the Medical Social Worker or the Chaplain. This was reviewed, discussed, and validated by the Director of Patient Care Services.