Every finding on record at Oxford Hospice Care, Inc.

Observed in Individual Tracer. In 5 of 10 patient records reviewed, the comprehensive assessment were not updated by all members of the interdisciplinary group. In RR#1 the chaplain, the social worker, and the MD signed at least 3 IDT notes however the sections designated for updates were left blank. RR#2 was seen by a podiatrist and the subsequent IDT was not updated related to this visit. Additionally, at least 1 IDT note was signed by the chaplain and MD however the sections for updates were left blank. RR#3, RR#5, and RR#7 had IDT(s) signed by the MD however the section for updates were left blank. This observation was discussed with the performance improvement LPN.

Observed in Individual Tracer. In 1 of 10 patient records reviewed, did not have accurate documentation in the record. Based on a review of the record of RR#8, the chaplain documented a assessment visit that had a date which preceded the start of care date for the patient. Per the performance improvement LPN, who spoke with the chaplain, there was issues with the electronic medical record at the time.

Observed in Individual Tracer. In 4 of 10 patient records reviewed, the hospice care plan goals were not measurable, individualized, or appropriate. RR#1 had the following goals- Patient will have an acceptable level of pain, the patient will have less cardiac symptoms, and blood sugar will be stable. RR#2- BP will be managed within 4 weeks, at the end of the certification period PCG and family will verbalize understanding regarding disease process and safety precautions related to oxygen. RR#6 -nausea and vomiting will be managed with Zofran by the end of certification. There was no further qualification of these goals. RR#8 had no goal related to end of life. Other goals listed on the care plan for RR#8 included - the patient will have optimum peripheral circulation and at the end of the certification period the patient will verbalize understanding that symptom is part of the disease process. The care plan of RR#10 reflected a goal of- optimum peripheral circulation and patient vital signs/labs will remain stable and not worsen. This observation was discussed with the performance improvement LPN.

Observed in Individual Tracer. In 1 of 10 patient records reviewed, the hospice orders/care plan did not reflect accurate or complete orders. The medication orders for RR#8 reflected- Diclofenac Sodium 1% cream topical 2x per day as needed for pain and Tylenol 325 mg every 6 hours as needed for pain. There was no further qualifications of these prn orders. This was discussed with the performance improvement LPN.

Observed in Infection Control System Tracer. Based on a review of the available data, there was no aggregated and or analyzed data related to hand hygiene for 2024, 2023, or 2022. Per the performance improvement LPN, the data was collected and maintained in individual employee files.

Observed in Individual Tracer. In 2 of 3 patient records reviewed, that received a hospice aide, did not have a comprehensive aide care plan based on the needs identified on the assessments. RR#3 & RR#4 were oxygen dependent and were on aspiration precautions and the hospice aide care plans did not reflect any of these precautions.

Observed in Individual Tracer. In 1 of 3 patient records reviewed, that had a hospice aide, did not have a supervisory visit no less frequently than every 14 days. RR#2 had documentation of a supervisory visit conducted in 30 days. This observation was discussed with the performance improvement LPN.

Observed in Individual Tracer. In 2 of 2 patient records reviewed, that was discharged to the hospital. DC#2 and DC#3 revoked seeking aggressive treatment. Both were sent to the hospital, discharge summaries completed however were not sent to the receiving facility/hospital based on chart review, discussions with DON and performance improvement LPN.

Observed in Emergency Management Session. It was noted that the organization did not document what authorities or how those authorities would be contacted if the organization could not contact on- duty staff during an emergency.

Observed in Emergency Management Session. It was noted that the organization did not document how or what authorities the organization would contact if the organization could not contact a patient or if a patient needed evacuation during an emergency.

Observed in Tracer Activities. It was noted that several hospice plans of care were not patient specific- for example the goals stated on more than one patient will have optimum heart rate for 7 days, or the patient will achieve the optimum circulatory status in 14 days, and the optimum blood sugars will be reached in 10 days. So optimums for these different patients were not specified for the particular patient or individualized for the patient.

Observed in Tracer Activities. It was noted that on two hospice home visits that the infection prevention policy was not followed. Personnel did not cleanse their hands before reaching into the clean side of the nursing bag.