Every finding on record at Orangecoast Partners

Observed in Record Review. In 1 of 10 patient records reviewed, for active patients, it was noted by the nurse surveyor that the comprehensive assessment was not completed within five calendar days of the election of hospice care per regulation. for RRHV#3, the Chaplain did not complete the Spiritual Assessment until eighteen days after the date of election of the hospice benefit. There was no documentation in the electronic medical record to indicate why the assessment was completed late. Finding was verified by the Nursing Director/Administrator.

Observed in Record Review. In 1 of 10 patient records reviewed, for active patients, it was noted by the nurse surveyor that the registered did not make a home visit to conduct an assessment on patients no less than every 15 days. For RRHV#1, there was a twenty-eight day period where only the Licensed Vocational Nurse (LVN) conducted the patient visits Finding was verified by the Director of Nursing/Administrator.

Observed in Record Review. In 10 of 10 patient records reviewed, for active hospice patients the nurse surveyor noted that the goals were not consistently measurable. For example, “Patient will have optimal nutritional status without complications,” and “Pain will be managed at a level acceptable to patient”. Additionally, most dates for the completion of goals were the end of the certification period. There were no short-term goals at admission to address medication administration or safety. Findings were discussed with the Director of Nursing/Administrator.

Observed in Record Review. In 7 of 10 patient records reviewed, for active patients, it was noted by the nurse surveyor that PRN frequencies were not quantified. For RRHV#1, RRHV#2, RRHV#3, RRNHV#2, RRNHV#3, RRNHV#5, and RRNHV#7, the nursing frequency and the social work frequency on the plan of care had open ended prn visits. For example, “skilled nurse visits two times a week and PRN symptom management” and “social work visits one time a month and prn social work needs’. Findings were verified with the Director of Nursing/Administrator.

Observed in Patient Home. In 1 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. For example, during RRHV#1 the CHHA used hand sanitizer, then donned gloves and assisted the caregiver to get the patient back in bed. She then changed gloves without hand sanitizing and proceeded to take her equipment out of her bag, cleaning her equipment prior to using on the patient, took the patient’s vital signs, cleaned her equipment again, put her equipment back in the bag, got the pans of bath water, then assisted in putting oxygen on the patient, all with the same pair of gloves on. Throughout the visit, the CHHA went in and out of her bag without performing hand hygiene. Findings were verified by the LVN who was present during the home visit.

Observed in Record Review. In 7 of 8 patient records reviewed, for active patients with the hospice aide, it was noted by the nurse surveyor that the hospice aide care plans did not contain all of the information for the hospice aide to effectively provide care. For RRHV#1, RRHV#2, RRHV#3 RRNHV#1, RRNHV#4, RRNHV#5, and RRNHV#7the care plan included that the hospice aide takes vital signs, but there were no parameters for when the registered nurse should be notified. Additionally, each of the patients were on oxygen prn however, there were no instructions to indicate if the patient’s oxygen could be removed during the bath if they were using it at the time. There also were no consistent instructions as to when the aide should notify the nurse for example if new skin breakdown was noted or for change in condition. Findings were verified by the Director of Nursing/Administrator.

Observed in Record Review. In 1 of 10 patient records reviewed, for active patents, it was noted by the nurse surveyor that Hospice Aide Supervisory visits were not documented the required every fourteen days per regulation. For RRHV#1, there were no documented Hospice Aide Supervisory visits for twenty-eight days. Findings were verified with the Director of Nursing/Administrator.

Observed in Record Review. In 4 of 10 patient records reviewed, for active patients, it was noted by the nurse surveyor that the authentication process had not been completed per the agency’s electronic medical record process for RRHV#1,RRHV#2, RRHV#3, and RRNHV#4. Finding was verified by the Director of Nursing/Administrator.

Observed in Patient Home. In 2 of 3 home visits conducted, it was noted by the nurse surveyor that for RRHV#1 and RRHV#2, the patients did not have an individualized disaster plan in their home folders. Finding was verified by the LVN who was present during the home visits. Discussion with the Director of Nursing/Administrator revealed that education is being provided and a form is filled out for agency use but is scanned as a part of the Electronic Medical Record. There is no process to develop an individualized emergency plan with the patient/family with a written plan in the home.