Every finding on record at Peace and Care Hospice, Inc.

Observed in Record Review. In 6 of 11 patient records reviewed, the update of the comprehensive assessment was not based on changes that have taken place since the initial assessment and did not include information about the patient’s progress toward desired outcomes and a reassessment of the patient’s response to care. In the chart for HV#2, the patient's problem of Potential for altered bowel elimination R/T diagnosis and co-morbidities., which was identified more than 4 months prior to the date of this survey, had a goal of In 4-5 weeks, Pt/Family/PCG will verbalize understanding r/t teaching that current GI symptom(s) is part of the disease process.,. The was also true of the problem of the potential for falls related to polypharmacy identified upon admission, more than 5 months prior to this survey. The goal was Risk of fall: In 1-2 weeks, Pt/Family/PCG will verbalize understanding of teachings re: increased risk of fall. These goals remained on the current POC. The anticipated achievement dates are getting updated with each meeting to two weeks out into the future. There is no documentation that these goals were actually met. In the chart for HV#1, ..In 1-2 days, diarrhea will resolve without complications AEB normalization of bowel elimination pattern & increased comfort., remained as an active goal from October 2021 on the current POC with no indication the goal was met. In the chart for HV#3, Effective 4/1/22 - Constipation: Patient will exhibit improved GI status, in 3-4 weeks, evidenced by normalization of bowel elimination pattern & increased comfort, absence of s/s referable to gastritis including heartburns., - target date keeps moving forward every IDT yet there was no documentation if this goal was met. This observation also applied to the goals in the charts for RR#1, RR#2, RR#3, RR#5. This was discussed with the Alternate DPCS.

Observed in Record Review. In 1 of 11 patient records reviewed, the patient record was not complete, promptly and accurately documented, readily accessible, and systematically organized to facilitate retrieval. In the chart for RR#5, during the comprehensive assessment, the RN documented that the patient had diarrhea, however also that the patient was constipated x 5 days. She medicated the patient for the constipation. This was discussed with the Alternate DPCS.

Observed in Record Review. In 1 of 11 patient records reviewed, the written plan of care was not based on the patient’s goals and the time frames, settings, and services required to meet those goals. In the chart for RR#4, the plan of care had no goals. This was discussed with the Alternate DPCS.

Observed in Record Review. In 2 of 11 patient records reviewed, the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions, including the following: Interventions to manage pain and symptoms. In the chart for RR#2, the LVN instructed the patient on use of cold packs for pain management. There was no order for this therapy on the hospice POC. In the chart for RR#4, there were no interventions on the POC except for pain medications. The LVN instructed the patient on use of cold packs and alternate pain management techniques. This was discussed with the Alternate DPCS.

Observed in Record Review. In 1 of 11 patient records reviewed, the hospice plan of care (POC) did not include all services needed for the palliation and management of the terminal illness and related conditions. In the chart for RR#5, the recertification POC did not include any frequency of aide visits. The aide was seeing the patient twice weekly. This was discussed with the Alternate DPCS.

Observed in Record Review. In 2 of 11 patient records reviewed, the plan of care (POC) did not include all services needed for the palliation and management of the terminal illness and related conditions and did not include treatments necessary to meet the patient's needs. In the chart for RR#4, there were no interventions on the POC except for medications and equipment/supplies. The patient was at risk for falls and pressure ulcer development. In the chart for RR#7, the LVN documented the patient was on CPAP. There was no order found for this treatment and it was not on the POC. This was discussed with the Alternate DPCS.

Observed in Record Review. In 1 of 11 patient records reviewed, the interdisciplinary group, in collaboration with the patient’s attending physician, if any, had not reviewed and revised the plan of care as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days. In the chart for HV#2, there were 17 days between IDT meeting/care plan review in the month prior to this survey. This was discussed with the Alternate DPCS.

Observed in Record Review. In 2 of 11 patient records reviewed, the organization had not provided the patient with care, treatment, or services according to the patient's individualized plan of care. In the chart for HV#3, the aide care plan instructed the aide to provide shaving weekly. This was not documented in either visit in weeks two and three of the current benefit period. In the chart for RR#3, vital signs were assigned to be performed by the aide. This was not completed in the last visit of the prior benefit period. This was discussed with the Alternate DON.

Observed in Data Session. The organization had not documented the reasons for conducting the chosen performance improvement projects. During the Data session, it was apparent that the organization collects, aggregates and analyzes data. However, the QAPI projects chosen for the current year were lacking any documentation about the reasons for choosing the projects. The listed projects included Revocations due to hospitalization, hand hygiene compliance, Pain management (bringing down the pain to comfort level within 48 hours of admission), etc. This was discussed with the Alternate DPCS.

Observed in Competency Session. The organization's education and training did not comply with law and regulation. The organization was not compliant with the CDC Core Infection Prevention Practice Category 2 - Education and Training of Healthcare Personnel on Infection Prevention which requires at least annual training on Infection prevention strategies. The organization had not adopted any infection prevention training except for at time of hire as confirmed with the Alternate DPCS. Observed in HR File Review. In 1 of 8 HR files reviewed, staff competence was not initially assessed and not documented as part of orientation. In the file for the Chaplain, the competencies required by the organization had not been evaluated at time of hire. For example, treating the patient/family as the unit of care, Philosophy of comfort, dignity, autonomy, quality of life and empowerment, Anticipatory grief. This was discussed with the Office Manager.

Observed in HR File Review. In 3 of 5 HR files reviewed, the organization had not verified and documented the following: Credentials of care providers using the primary source when licensure, certification, or registration is required by law and regulation to practice their profession. This was not done at the time of hire or when the credentials were renewed. In the file for the DPCS, the license which expired 12/31/20 was not verified as renewed until 1/22/21. The Medical Director license which expired 9/30/20 was not verified as renewed until 10/19/21. The license for the RN/Bereavement Coordinator was not verified until more than three months post-hire. This was discussed with the Office Manager.