Every finding on record at One Stop Hospice, Inc.

Observed in Record Review. In 12 of 14 patient records reviewed, the Surveyor noted patient plan of care (POC) goals and interventions that had not been specific to the patient and their needs nor measurable. Examples include: The patient will maintain physical mobility with limitations, The patient will not sustain fall, The patient Foley catheter will remain patent during this certification period, The patient will have an acceptable respiratory rate of 12-20 breaths per minute during this certification period, The patient’s pacemaker function will be without complications, with no lead dislodgement noted for the next 2 week, Patient will be comfortable for the next 2 weeks of Hospice care and The patient will not develop any episodes of respiratory crisis for the next 2 weeks. This was evident in every record reviewed. This was validated with the DPCS and the Administrator.

Observed in Record Review. In 1 of 14 patient records reviewed, the Surveyor noted as needed medications without clear indications for use. For example, RRNHV #6 the patient had Zofran, Compazine oral, Compazine rectal and Dimenhydrinate ordered for nausea without clear instructions. The patient also had the pain medication Morphine and Oxycodone ordered for pain management without clear indications for use. This was validated with the DPCS. Observed in Record Review. In 4 of 14 patient records reviewed, the Surveyor noted patient care orders specific to wound care and device management to be incomplete. For example, in RRHV #3 the patient had a right leg calf wound with orders: Cleanse with normal saline and pat dry. Cover with triple antibiotic ointment and island dressing. Change twice weekly and as needed if soiled or dislodged; however, the order had not stated who was to complete the dressing change. In RRHV #4 the patient had an indwelling catheter with orders to: Insert Foley catheter 16 Fr 10 cc balloon due to urinary retention. Change Foley monthly and as needed if leaking, clogged or dislodged without specifying who was to complete the change. The same patient also had wound care orders which had not identified who was to complete the wound care. Both the patient's in RRNHV #13 and RRNHV #14 had wound care orders without specifying who was to complete the care. This was validated with the DPCS and Administrator Observed in Record Review. In 1 of 14 patient records reviewed, the Surveyor noted the patient plan of care (POC) had not contained all the patient issues requiring interventions. for example, the patient in RRNHV #6 had a urinary tract infection and started on antibiotics; however this had not been discussed at IDG and added to the patient POC. This was validated with the DPCS and Administrator.

Observed in Record Review. In 3 of 14 patient records reviewed, the Surveyor noted that care was not provided according to the plan of care (POC). For example, in RRHV #1, the patient had orders for spiritual care (SC) provider to see the patient monthly; however there had been no documented visits in July, August or September. in RRNHV #7, the patient had orders to change the indwelling catheter every 30 days; however, there had been no documented change of the device in the month of September. RRNHV #14, the patient had SC ordered for monthly visits; however, there had been no documented visit in September. This was validated with the DPCS and Administrator.

Observed in Patient Home. In 3 of 4 home visits conducted, the Surveyor noted that staff hand hygiene was out of compliance with the HCO policy. For example, in RRHV #1, the clinician had changed gloves 5 times without performing hand hygiene between the changes. In RRHV #3, the clinician had gone into her clinical bag 3 times without first performing hand hygiene. The same clinician changed her gloves 2 times without performing hand hygiene. RRHV #4, the clinician entered her bag 3 times without performing hand hygiene and also had not performed hand hygiene between glove changes 6 times . This was validated with the DPCS present during the visit. Observed in Patient Home. In 3 of 4 home visits conducted, the clinicians had not followed the HCO policy on cleaning of equipment utilized during patient visits. Policy was to clean the equipment with alcohol; however, in RRHV #1, RRHV #2 and RRHV #4 the clinicians had used Clorox wipes on all equipment. The clinicians could not state the dwell time for the Clorox wipes nor that the equipment needed to remain visibly wet. In RRHV #4, the clinician had been observed squeezing the liquid from the wipe prior to using as she wanted it dryer. This was validated with the DPCS present during the visits.

Observed in Record Review. In 1 of 14 patient records reviewed, the Surveyor noted the Hospice Aide plan of care (POC) for RRNHV #12 had not included the type of bath the patient should be given. This was validated with the DPCS.

Observed in Tracer Activities. During review of the Volunteer program,, there was no documentation to validate cost savings had been achieved using volunteers. In discussion with the Volunteer Coordinator, information regarding cost savings is not being tracked nor documented because they have not had any volunteers over the last three years. The agency stated they enacted the volunteer waiver but no official documentation in their emergency management minutes stating which waivers they were following and since the public health emergency ended 5 months ago the agency has been actively recruiting for volunteers but has no volunteers so no cost report was created. This was reviewed and validated with the Administrator and DPCS.

Observed in Tracer Activities. Identified during the review of the Volunteer Program, there was no volunteer hours achieved since the public health emergency ended 5 months ago, thus the 5 percent of the total patient care hours requirement was not achieved. Agency lost all volunteers during COVID and has not been able to recruit any new ones and has not volunteers. Agency does have an active performance improvement plan in place related to recruitment of volunteers. This was reviewed and validated with the Administrator and DPCS.

Observed in Record Review. In 2 of 2 discharged patient records reviewed where patient discharged from service, a discharge summary for care and treatment was not sent to the provider or a notification given that it was available on request. In RRDC #1, the discharge summary indicated the patient had an extended diagnosis, a summary was written but it was not sent to physician who would be providing care after discharge and notification of it's availability was not completed. In RRDC #2, the patient revoked care for a higher level of care. The discharge summary was completed but was not sent to the receiving provider or notification of its availability given to them. This was reviewed and validated with the DCPS and Administrator.

Observed in Record Review. In 1 of 14 patient records reviewed, of active patients, The Surveyor noted the HCO had not followed their policy on timeliness of documentation which states documentation is to be completed and in the record within 72 hours. For example, RRNHV #6, the Hospice Aide ordered for 3 times per week, had not documented any visits for the last 2 weeks of October. The Surveyor had been able to validate that the visits had been completed. This was validated with the DPCS and Administrator.