Every finding on record at Pinnacle Hospice Care LLC

Observed in Emergency Management Session. The organization did not evaluate its emergency management program, emergency operation plan, and continuity of operations plans. During the Emergency Management Session, it was noted that although the organization had conducted drills and exercises of it's emergency management/operations plan, there was no documented evaluation or after-action report of the drills/exercises conducted. This was reviewed and verified with the Chief Operations Officer.

Observed in Record Review. In 1 of 14 patient records reviewed, the organization did not assess the patient according to defined timeframes by ensuring the comprehensive assessment was completed no later than five (5) calendar days of the election of hospice care. In RRHV#1, the initial bereavement assessment was completed/documented by the Spiritual Care Counselor 29 days after the patient's election of hospice care. This was reviewed and verified with the Chief Operating Officer.

Observed in Record Review. In 10 of 10 patient records reviewed, the organization did not plan the patient's care by ensuring the written plan of care was based on the patient's goals and the timeframes, settings, and services required to meet those goals. In RRHV#1, RRHV#2, RRHV#3, RRNHV#1, RRNHV#2, RRNHV#3, RRNHV#4, RRNHV#5, RRNHV#6, and RRNHV#7, the patient's plan of care goals were non-specific with no measurability or timeframes for achieving goals. Example of selected/documented patient goals in the hospice electronic record included: Facilitating and creating a sense of support for adaptation, Establishing or regaining normal pattern of bowel function, and Establishing various and creative methods of communication. This was reviewed and verified with the Administrator.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization did not plan the patient's care by ensuring the registered nurse prepared written care instructions for the hospice aide. In RRHV#3, the Hospice Aide Care Plan did not include instructions for the use of a rolling shower chair when providing a shower bath for the patient with a history of falling, right humerus fracture, abnormalities of gait and mobility, muscle weakness, and age-related physical debility. This was reviewed and verified with the Administrator.

Observed in Record Review. In 1 of 9 patient record reviewed with hospice aide services, the organization did not provide care, treatment, or services in accordance with orders and regulation. In RRNHV#3, the hospice aide did not report changes related to the patient's condition and plan of care needs to the registered nurse. The aide documented on the most recent visit note checked buttock and noticed an abrasion. The was no evidence/documentation that the hospice aide had notified the supervising RN of the abrasion. This was reveiwed and verified with the Administrator.

Observed in Patient Home. In 3 of 3 home visits conducted, the organization did not provide patient education and training based on each patient's needs and abilities. In RRHV#1, RRHV#2, and RRHV#3, education and training was not provided to the patient/caregiver including the procedures to follow if care, treatment, or services were disrupted by a natural disaster or an emergency. There was no individualized emergency plan provided to the patient/caregiver in the home. This was reviewed and verified with the Administrator.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization did not manage safety risks and take action to minimize the identified risks. In RRHV#1, the patient's oxygen E-Tank was stored is small closed clothes closet in patient's bedroom. The hospice staff had not taken action to educate the caregiver and ensure relocation of the oxygen tank to a safe well-ventilated area. This was reviewed and verified with the Administrator.

Observed in Patient Home. In 1 of 3 home visits conducted, the organization did not implement the infection prevention and control activities it had planned to minimize, reduce, or eliminate the risk of infection. In RRHV#3, the Hospice Aide used an open reusable grocery bag to carry and store care equipment. The use of this type of field bag was not in compliance with the organization's Bag Technique policy and procedure. This was reviewed and verified with the Administrator.