Every finding on record at Ohio's Hospice of Fayette County Inc.

Observed in Document Review. In 2 of 8 patient records reviewed, The HCO staff failed to complete the initial nursing assessment within the defined time frame. For example, the surveyor noted on RR #4 and RR #5, the registered nurse completed the patient’s initial assessment a day prior to the patient’s date of electing hospice, while the patient remained hospitalized. Standards require the hospice registered nurse completes the initial assessment of the patient within 48 hours of the election of hospice care, not prior. These findings were reviewed, discussed and confirmed with the Executive Director and Team Leader.

Observed in Record Review. In 4 of 8 patient records reviewed, The HCO did not ensure an initial comprehensive assessment was completed within five days of the patient electing the hospice benefit. For example, the surveyor noted on patient HV #1/RR #1, RR #4, RR #7 and RR #8, there was no documentation that an initial spiritual care assessment was completed as a part of the admission comprehensive assessment. Standards require a comprehensive assessment, including psychosocial and spiritual care be completed within five days of a patient electing hospice care. These findings were reviewed, discussed, and validated with the Executive Director and Team Leader.

Observed in Record Review. In 1 of 8 patient records reviewed, The HCO failed to ensure the interdisciplinary group review/update the patient’s plan of care at least every 15 days. For example, the surveyor noted on HV #3/RR #3, documentation of the interdisciplinary group review of the patient plan of care was not present in the patient’s health records between the patient’s admission date of 03/25/2021 and 04/28/2021. Standards require the hospice interdisciplinary group review and revise the patient’s plan of care as frequently as required, but no less than every 15 calendar days. These findings were reviewed, discussed, and confirmed with the Executive Director and the Team Leader.

Observed in Patient Home. In 1 of 3 home visits conducted, The HCO staff failed to use standard infection prevention and control precautions at times required by the organization's policies. For example, on HV #1/RR #1, the surveyors observed the registered nurse touching broken skin to the patient’s right leg without donning gloves first. Additionally, the nurse was observed cleaning the medical equipment and placing them back on the dirty side of the barrier. The organization’s hand hygiene and bag technique policies require standard precautions be used, including wearing gloves when assessing non-intact skin areas and maintaining a clean and dirty side of bag contents. These findings were reviewed, discussed, and confirmed with the Executive Director and Team Leader.

Observed in Record Review. In 1 of 8 patient records reviewed, The patient’s certification of terminal illness(CTI) lacked required elements. For example, the surveyor noted on HV #2/RR #2, the physician had signed the CTI but did not check/document the determination of the patient’s life expectancy. Standards require the medical director or designee provide written certification of the determination of the patient’s life expectancy. These finding were reviewed, discussed and confirmed with the Executive Director and Team Leader.