Every finding on record at Onyx Hospice, Inc.

Observed in Record Review. In 1 of 8 patient records reviewed, for active patients, the nurse surveyor noted that the plan of care was not complete. For RRHV#1 the patient had oxygen in the home yet there was no order for the oxygen. Finding was verified by the QAPI Educator and the Administrator/Director of Patient Care Services.

Observed in Patient Home. In 3 of 3 home visits conducted, it was observed by the Nurse Surveyor that the organization did not implement the infection prevention and control activities it had planned per their “Hand Hygiene Policy No. 9-009.1”. For example, during RRHV#1 the skilled nurse did not hand sanitize after touching the patient and reaching into her pocket for her phone. She documented on the phone, then resumed taking the patient’s vital signs without performing hand hygiene. During RRHV#2 the skilled nurse, had gloves on and had started the patient’s assessment, she then pulled the patient’s drapes down to ensure privacy, however she did not change gloves or hand sanitize prior to resuming the patient assessment. During RRHV#3 the hospice aide double gloved without hand sanitizing, then prepared the supplies needed to bathe the patient. Prior to bathing, she took off the top pair of gloves then proceeded to bath the patient head to toe with the same pair of gloves on. Observed in Patient Home. In 1 of 3 home visits conducted, the nurse surveyor noted that the organization did not implement the infection prevention and control activities it had planned per their “Bag Technique Policy No. 9-041.1”. During RRHV#3, the hospice aide set her bag down on an upholstered chair in the hallway outside the patient’s room without a barrier. Additionally, she went in and out of her bag without changing her gloves or performing hand hygiene.

Observed in Patient Home. In 1 of 1 home visits conducted, with the hospice aide, it was noted by the nurse surveyor that for RRHV#3 the hospice aide did not provide care according to the hospice aide plan of care. The hospice aide applied A&D ointment to the patient’s skin as she noted that she liked it better than lotion. Neither was on the hospice aide plan of care.

Observed in Record Review. In 1 of 5 patient records reviewed, The organization failed to ensure the medical director, physician member of the interdisciplinary team, or physician designee review the clinical information for each hospice patient and provide written certification that the patient’s life expectancy is six months or less if the illness runs its normal course. For example: Upon review of RR#3 there was no documentation of an initial CTI noted on the clinical record. This observation was reviewed with the Administrator/DPCS.

Observed in Record Review. In 1 of 1 patient records reviewed, to be admitted after September 2022 the organization failed to ensure that all entries to the record be appropriately authenticated and dated in accordance with organization policy. For example: upon review of RR#2 in the patient record the Informed Consent and Treatment Authorization was signed with the employee name, signature, yet the entry was not dated. The POLST was signed by the physician but not dated. This observation was reviewed with the Administrator/DPCS.

Observed in Leadership Session. During review of the Emergency Management Plan it was noted the organization had ensured the plan maintained the names and contact information of the following: entities providing services under arrangements. This was reviewed and validated with the Administrator/Director of Patient Care Services.

Observed in Patient Home. In 2 of 2 home visits conducted, During HV# 1 and HV# 2's home observation it was noted the Licensed Vocational Nurse (LVN) had not followed the organization's Bag Technique policy that included cleaning the stethoscope, thermometer, and pulse oximetry with alcohol. For example: during HV# 1 and HV# 2's home observations the LVN cleaned the stethoscope, thermometer, and pulse oximetry with a bleach wipe. This was observed, reviewed, discussed, and validated by the Administrator/Director of Patient Care Services.

Observed in Leadership Session. 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, and §418.60.

Observed in HR File Review. In 1 of 1 contracted HR files reviewed, During HR# 8's HR file review it was noted the organization had not provided orientation to the alternate Medical Director. For example: review of the HR file revealed no documentation of an orientation and the Human Resources Director shared the organization did not orient contracted staff.

Observed in HR File Review. In 1 of 1 Contracted HR files reviewed, During HR# 8's HR file review, it was noted the organization had not ensured the alternate Medical Director had an initial competence evaluation completed. This was discussed and validated with the Administrator/Director of Patient Care Services. Observed in HR File Review. In 1 of 1 contracted HR files reviewed, During HR# 8's HR file review it was noted the organization had not provided education and training compliant with OSHA requirements that would include annual Infection Control, Tuberculosis, and Blood Borne Pathogens training annually or offer the Hepatitis B vaccine to the employee as required by OSHA regulations. For example: review of HR# 8's HR file revealed no education on hire or annually and no documentation the Hepatitis B vaccine was offered. This was reviewed and discussed with the Human Resource Director and validated.

Observed in Record Review. In 4 of 4 patient records reviewed, During HV# 1, HV# 2, BR# 1, and RR# 1's patient records review it was noted the organization had not ensured an initial certificate of terminal illness (CTI) was completed by the Medical Director. For example: review of HV# 1's patient record revealed no initial CTI. Review of HV# 2's patient record revealed no initial CTI. Review of RR# 1's patient record revealed no initial CTI. Review of BR# 1's patient record revealed an initial CTI with no Medical Director signature This was reviewed, discussed and validated by the Administrator/DPCS.

Observed in Record Review. In 4 of 4 patient records reviewed, During HV# 1, HV# 2, BR# 1's, and RR# 1's patient records review it was noted the organization had not ensured all entries into the patient record were authenticated. For example: review HV# 1's patient record revealed 20 of 20 Home Health Aide (HHA) visits notes with no signatures. Further review of the HV# 1's patient record revealed an Informed Consent and Treatment Authorization form with an employee name and no signature, discipline, or date. Review of HV# 1's certificate of terminal illness (CTI) revealed no Medical Director signature. Review of HV# 2's patient record revealed all three of the RN supervisory visits with no signatures. Further review of HV# 2's patient record revealed 15 of 15 HHA visit notes with no signatures. Review of HV# 2's patient record revealed a recertification CTI with no Medical Director Signature. Review of BR# 1's patient record revealed an Informed Consent and Treatment Authorization form with an employee signature and no date. Further review of the patient record revealed BR# 1 was admitted approximately 8 months prior to the surveyor review of the record. Review of BR# 1's initial CTI revealed no Medical Director signature. Review of RR# 1's patient record revealed an Informed Consent and Treatment Authorization form with an employee signature and no date. Further review of RR# 1's record revealed 20 of 20 HHA visit notes with no signature and four RN supervisory visits with no signature.. This was reviewed, discussed, and validated by the Administrator/DPCS.