Every finding on record at One Care Hospice, Inc.

Observed in Patient Home. In 1 of 3 home visits conducted, the Surveyor noted the medication profile in the electronic medical record (EMR) had not been updated to reflect the medications the patient was currently being administered. For example, in HV #1, the EMR had been missing the medication Amiodorone 200 mg that the patient had been taking for over 5 months. This was validated with the Director of Patient Care Services.

Observed in Record Review. In 3 of 3 patient records reviewed, the Hospice Surveyor noted an Interdisciplinary Group meeting that occurred the last week of February had been signed by only the Registered Nurse. There had been no method of validating the participation of the MSW, Chaplain or Medical Director. The Surveyor reviewed the IDG meeting notes again the following day and found that all of the missing signatures had been added to the document. Discussion related to the ability of the clinicians to back sign a document, revealed that while a document is unlocked within the EMR, the note and signatures can be amended. This was validated with the Director of Patient Care Services. Observed in Record Review. In 3 of 3 patient records reviewed, the Hospice Surveyor noted an Interdisciplinary Group meeting that occurred the last week of February had been signed by the Registered Nurse only and no other clinicians. The Surveyor reviewed the IDG meeting notes again the following day and found that all of the signatures had been added to the document. Discussion related to this identified that while a document is unlocked within the EMR, the note and signatures can be amended. The EMR currently in use automatically back dates signatures to the date the document was created rather than the date signed. This was validated with the Director of Patient Care Services.

Observed in Record Review. In 4 of 5 patient records reviewed, the organization did not include goals that were specific, measurable or timed and based on the patient and family problems identified in the comprehensive assessment. For example, upon review of documentation in the records, for HV #1 the goals included: patient will have comfortable bowel elimination, patient will be free of preventable discomfort. In HV #2 the goals included: the patient will have no injury due to oxygen, the patient will maintain physical strength. In HV #3 the patient goals included: the patient will have adequate food and maintain nutritional status. This was discussed and validated with the Administrator/Director of Patient Care Services.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization did not implement the infection prevention and control activities it had planned. According to organizational policy Hand Hygiene (no number available) hand hygiene is required after removing gloves, after direct contact with patient and prior to entering the nursing bag. During HV#3, the clinician was observed assessing patient, removing gloves and entering bag without sanitizing hands. This was discussed with the Owner/CEO and Administrator/Director of Patient Care Services following the visit. Observed in Patient Home. In 1 of 3 home visits conducted, the organization’s infection prevention and control activities related to equipment disinfection were not implemented. During HV #3, the clinician was observed cleaning the vital sign equipment with the disinfectant Cleancide Germicidal Wipes. The equipment was immediately returned to the nursing bag without allowing contact time. According to the manufacturer's instruction for use, contact time is from 3-5 minutes.This was discussed with the Administrator/Director of Patient Care Services and Owner/CEO following the visits.

Observed in Regulatory Review. “The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews: - §418.100, 418.102, 418.56

Observed in Leadership Session. the organization did not designate a physician to serve as the alternate medical director to assume the responsibilities and obligations should the medical director become unavailable. This was discussed with the Administrator/Director of Patient Care Services and the Owner/CEO who stated they were actively searching for one. The organization executed a Contract for physician designee while surveyor was on site including the personnel file and health record documents.