Every finding on record at Ospta Home Care and Hospice

Based on review of Clinical Records (CR), agency Policy and Procedure, and staff (EMP) interview, the hospice failed to ensure the Plan of Care (POC) included interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments for two (2) of nineteen (19) CR reviewed (CR 1 & 9). --- Findings included: Review of agency Policy and Procedure on 4/7/23 at approximately 10:00am revealed: "Physician Orders...PROCEDURE, 1. The IDG plan of care is established in consultation with the physician, Medical Director, Hospice staff, the patient, and members of the patient's family. The plan of care may include: ...Specific procedures deemed essential..." "IDG Care Planning Process...PROCEDURE...2. The care plan specifies the care and services necessary to meet the patient and family specific needs identified in the comprehensive assessment..." CR 1, start of services (SOS) 1/7/22, benefit period reviewed 1/7/22-4/6/22. CR review on 4/7/23 at approximately 12:20pm revealed Plan of Care (POC) included "...Foley to gravity drain/ change 4-6 weeks & prn/Irrigate with 30ml NSS prn..." CR failed to include order indicating foley size and balloon size to be used. CR 9, SOS 10/22/21, benefit period reviewed 2/14/23-4/14/23. CR review on 4/5/23 at approximately 12:00pm revealed POC included "...Change foley catheter as ordered..." CR failed to include an order for foley catheter indicating foley size, balloon size, frequency of change, and/or instructions to flush. Findings confirmed in exit interview on 4/7/23 at approximately 2:00pm with Owner, Administrator, Director of Clinical, and Home Health Administrator.

Based on observation of home visits (OBS), review of agency policy and procedure, and staff interview (EMP), the hospice failed to ensure clinical staff follow accepted standards of practice to prevent the transmission of infections and communicable diseases for one (1) of four (4) home visit observations conducted (OBS 3). --- Findings included: Review of Agency policy/procedure on 4/7/23 at approximately 10:00am revealed: "Specific Procedure for Employee and Patient Infection Control Training...PROCEDURE...1. All employees who come into contact with blood, body fluids, tissue, solids, or any moist bod part or substance of any patient will use the following specific procedures in compliance with standard procedures: Apply gloves before contact with any moist body site, fluids or solids, including mucous membranes (e.g. examining patients with bleeding or open lesions, large abrasions or dermatitis) and when handling items soiled with body fluids or substances..." Agency did not have a policy that includes hand hygiene and use of gloves as it specifically relates to wound care. CR 18, start of services (SOS) 3/17/23, benefit period reviewed 3/17/23-6/14/23. During home visit OBS3, conducted on 4/5/23 at approximately 8:30am the skilled nurse failed to don gloves prior to applying clean dressing to gastric tube vent site. Findings confirmed in exit interview on 4/7/23 at approximately 2:00pm with Owner, Administrator, Director of Clinical, and Home Health Administrator.

Based on review of agency Policy and Procedure and clinical records (CR), the agency failed to ensure that bereavement services reflect the needs of the bereaved for three (3) of three (3) bereavement records reviewed (CR3-5). --- Findings included: Review of agency bereavement program on 4/7/23 at approximately 1:30pm revealed: "Bereavement Low Risk Guidelines, Intervention, Initial & 1st Month-Call or visit within 72 hours, Funeral Visitation if applicable, Plaque wit poem to funeral home or family if appropriate, Initiate Bereavement Plan of Care, Sympathy Card with Bereavement Resource list; 2nd Month- Phone Call; 3rd Month Stages of Grief Mailing with Magnet; 4th Month- Coping Skills Mailing; 6th Month-Grief and Stress Mailing; 9th Month-Mailing; 12th Month-Anniversary Letter; 13th Month-Closing Letter and Survey..." Interview with Bereavement Coordinator on 4/6/23 at approximately 8:30am revealed bereavement coordinator uses a tracking spread sheet to monitor bereavement tasks due and documents tasks in each CR. CR3, reviewed 4/7/23 at approximately 12:50pm revealed date of death 2/9/23, bereavement record reviewed post-death. Bereavement risk identified as low. Bereavement record failed to include documentation of bereavement follow up. No documentation in record of contact by phone or mail to bereaved. CR4, reviewed 4/7/23 at approximately 1:00pm revealed date of death 1/2/23, bereavement record reviewed post-death. Bereavement risk identified as low. Bereavement record failed to include documentation of initial post death contact and 3-month mailing. CR5, reviewed 4/7/23 at approximately 1:20pm revealed date of death 7/30/22, bereavement record reviewed post-death. Bereavement risk identified as low. Bereavement record failed to include documentation of initial post death contact and 4-month mailing. Interview with Administrator on 4/7/23 at approximately 1:45pm revealed agency difficulty understanding bereavement functions of new electronic documentation system. Findings confirmed in exit interview on 4/7/23 at approximately 2:00pm with Owner, Administrator, Director of Clinical, and Home Health Administrator.

Based on the review of clinical records (CR), home visit observations (OBS), and staff interview (EMP), the hospice failed to specifically identify which provider is responsible for performing the respective functions that have been agreed upon and included in the hospice plan of care for four (4) of nineteen (19) clinical records reviewed (CR6, 11, 16, & 18) (OBS 3). --- Findings included: CR 6, start of services (SOS) 2/10/23, benefit period reviewed 2/10/23-5/10/23. CR review on 4/4/23 at approximately 12:15pm revealed Plan of Care (POC) physician to be patient's Primary Care Physician (PCP). Upon review of additional clinical documentation, it was found that all orders in CR had been sent to a Hospice physician, not POC signing physician. CR 11, start of services (SOS) 3/17/23, benefit period reviewed 3/17/23-6/14/23. CR review on 4/5/23 at approximately 12:45pm revealed POC physician to be patient's PCP. Upon review of additional clinical documentation, it was found that all orders in CR had been sent to a Hospice Medical Director, not POC signing physician. CR 16, start of services (SOS) 2/15/23, benefit period reviewed 2/15/23-5/15/23. CR review on 4/7/23 at approximately 11:55am revealed POC physician to be patient's PCP. Upon review of additional clinical documentation, it was found that all orders in CR had been sent to a Hospice Medical Director, not POC signing physician. CR 18, start of services (SOS) 3/17/23, benefit period reviewed 3/17/23-6/14/23. During home visit OBS3, conducted on 4/5/23 at approximately 8:30am the patient revealed that at recent visit with PCP, the PCP reported no communication from "anyone", the patient clarifying this to be the hospital and Hospice. Review of Hospice POC at this time revealed PCP to be POC signing physician. Upon review of additional clinical documentation on 4/7/23 at approximately 12:30pm, it was found that all orders in CR had been sent to Hospice Medical Director, not POC signing physician. During interview with Administrator and Director of Clinical on 4/7/23 at approximately 10:45am, Administrator stated, "...Some attendings want constant, more involved oversight of everything. Some only want updates every 2 weeks..." At this time Hospice Administrator confirms there is no way to identify the level of involvement of attending or what specific parts of the POC they will oversee. Findings confirmed in exit interview on 4/7/23 at approximately 2:00pm with Owner, Administrator, Director of Clinical, and Home Health Administrator.