Every finding on record at Pd Hospice, Inc.

Observed in Record Review. In 1 of 1 staff interviews, related to patient complaints, the organization failed to allow the patient/ family/ CG the right to have complaints reviewed per organizational policy. During home visit for RRHV#2, the Med Tech at the facility advised this surveyor that she had called the Hospice the week prior regarding a family complaint related to the HHA visit. She stated that the family told her the HHA stayed only 10 minutes and that the patient was still very wet and his clothes were wet. The organization advised this surveyor that the complaint was taken by the office manager and that she also documented it. The organizational policy stated that the staff receiving the complaint will discuss, verbally and in writing, the grievance with the clinical supervisor/ nursing supervisor and the clinical supervisor/ nursing supervisor will investigate the grievance. The Nursing Supervisor was unaware of the complaint until she heard the Med Tech advise the surveyor of the situation. And the complaint documentation did not state that the nursing supervisor was included. This was discussed and reviewed with the Hospice DPCS Designee.

Observed in Record Review. In 4 of 15 patient records reviewed, the organization failed to assess the patient condition according to defined time frames. During record review for RRHV#3, RRNHV#4, RRNHV#5 and RRNHV#8, the Hospice Nurse Surveyor observed the organization did not have documentation of why the initial nursing assessments were not completed within 48 hours. This was discussed and reviewed with the DPCS Designee.

Observed in Record Review. In 15 of 15 patient records reviewed, the organization failed to assess and reassess as defined by policy. During record review for all records, the Hospice Nurse Surveyor observed the initial Psychosocial, Spiritual and Bereavement Assessments were completed telephonically with no documentation that in person visits were offered. All documentation stated pt/cg agreed to telephonic. For all records reviewed, the POC stated may do telephonic remote visits as applicable and as per patient request. Staff were not following the POC. The SW stated in an interview with the surveyor that since the pandemic all visits were done remotely due to potential risk, unless the patient specifically requested in person. This was discussed and reviewed with the Hospice DPCS Designee.

Observed in Record Review. In 6 of 15 patient records reviewed, the organization failed to assess and reassess its patients. During record review for RRHV#3, RRNHV#2, RRNHV#7, RRNHV#8, RRDC#1, and RRDC#2, the Hospice Nurse Surveyor observed the Registered Nurse was not making visits at least every 15 days. The organization utilized primarily LVN's. For example in RRNHV#7, the patient had a gap in RN visits of 5 weeks. In RRNHV#8, the RN had not visited in over a month. In RRDC#1, the RN had a gap in visits of almost 3 months, and in RRDC#2, the RN had a gap in visits of 6 weeks. This was discussed and reviewed with the DPCS Designee.

Observed in Record Review. In 1 of 17 patient records reviewed, the organization failed to provide care, treatment, or services in accordance with orders, as required by law and regulation. During record review for RRHV#1, the Hospice Nurse Surveyor observed visit frequency orders were not being following. For RRHV#1, the SW and SC were ordered monthly but they were only going at recertification. The RN was ordered once every other week. But did not go at all during the month of December and then had a lapse of 21 days between Jan/ Feb. This was discussed and reviewed with the Hospice DPCS Designee.

Observed in Record Review. In 15 of 15 patient records reviewed, the organization failed to coordinate the patient's care, treatment, or services based on the patient's needs. During record review for all records the Hospice Nurse Surveyor observed the SC/SW/Bereavement assessments were being done telephonically with the staff documenting notes that patient/CG agreed. The POC of all patients stated may do telephonic remote visits as applicable and as per patient request. Staff were not following the POC. The SW stated in an interview with the surveyor that since the pandemic all visits were done remotely due to potential risk, unless the patient specifically requested in person. This was discussed and reviewed with the Hospice DPCS Designee.

Observed in Patient Home. In 2 of 3 home visits conducted, the organization failed to implement the infection prevention and control activities it had planned. During home visits for RRHV#1 and RRHV#2, the Hospice Nurse Surveyor observed staff did not follow the organizational policy for hand hygiene. For example in RRHV31, the nurse did not do hand hygiene each time she re-entered her nursing bag. And in RRHV32, the Chaplain did not do hand hygiene before touching the patient or after touching the patient's blankets. This was discussed and reviewed with the Hospice DPCS Designee. Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to implement the infection prevention and control activities related to reusable medical equipment they had planned. During home visit for RRHV#1, the Hospice Nurse Surveyor observed the nurse utilize generic brand Clorox wipes to clean her blood pressure cuff, pulse oximeter, stethoscope and thermometer. She immediately dried them with a loose paper towel from her bag. The organizational policy stated equipment would be washed with soap and water or alcohol. This was discussed and reviewed with the Hospice DPCS Designee.

Observed in Record Review. In 4 of 5 patient records reviewed, patients receiving aide services, the organization failed to supervise staff effectively. During record review for RRHV#1, RRHV#3, RRNHV#5, and RRDC#1 the hospice aides were not being supervised at least every 14 days. For example in RRHV#1, the Hospice Nurse Surveyor observed the Hospice Aide Supervision had not been performed for 53 days. This was discussed and reviewed with the Hospice DPCS Designee.

Observed in Tracer Activities. There was no evidence that the governing body and leadership had established requirements to support patient care, treatment and services as evidenced by lack of implementation of policy for patient assessments, aide supervision, notice of non-coverage implementation, and the complaint process/ policy. This was discussed and reviewed with the Hospice DPCS Designee.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization failed to provide patient education and training based on each patient's needs and abilities. During home visit for RRHV#1, the Hospice Nurse Surveyor observed the oxygen sign was not on the door and that the oxygen concentrator and portable tanks were being stored in a closet. Upon record review, it was noted that there was no documentation of education to the family related to these items. This was discussed and reviewed with the Hospice DPCS Designee.

Observed in Record Review. In 3 of 3 patient records reviewed, that required an ABN, the organization failed to involve the patient in making decisions about their care, treatment, or services. During record review for RRDC#1, RRDC#2, and RRNHV#4, the Hospice Nurse Surveyor observed the documentation of the Notice of Non-Coverage was not signed at least 48 hours before discharge. For example RRDC#1 and RRDC#2 were signed the day before discharge and RRNHV#4 was signed the same day. This was discussed and reviewed with the DPCS Designee.

Observed in Patient Home. In 1 of 1 home visits conducted, patients with oxygen orders, the organization failed to manage safety and security risks related to oxygen storage. During home visit for RRHV#1, the Hospice Nurse Surveyor asked the caregiver if the patient had oxygen ordered. The nurse stated she did not. The caregiver led the surveyor to a closet where a concentrator and portable oxygen container were being stored with the closet door closed. The organization's policy stated that oxygen would not be stored in a closet. The nurse and the DPCS designee did not step in during the visit to assist and did not offer education to the caregiver. The DPCS designee did advise she would be sending an RN out to remedy the situation. This was discussed and reviewed with the Hospice DPCS Designee.