Every finding on record at Pinnacle Hospice Care of Portland

Observed in Record Review. In 8 of 14 patient records reviewed, During BR# 1, BR# 2, RRHV# 1, RRHV# 2, RRHV# 3, RRNHV# 3, RRNHV# 4, RRNHV# 6, and RRNHV# 7's patient records review it was noted the organization had not ensured the comprehensive assessment was completed no later than five calendar days after the election of hospice care. For example: review of RRHV# 2's patient record revealed an initial bereavement assessment completed 46 days after the election of hospice care. Further review of RRHV# 2's patient record revealed the MSW completed the initial psychosocial assessment 12 days after the election of hospice care. Review of RRHV# 1's patient record revealed an initial bereavement assessment completed 12 days after the election of hospice care. Review of RRHV# 3's patient record revealed an initial bereavement assessment completed 113 days after the election of hospice care. Review of RRNHV# 3's patient record revealed an initial bereavement assessment completed 58 days after the election of hospice care. Review of RRNHV# 6 revealed an initial MSW psychosocial assessment dated eight days after the election of hospice care and an initial bereavement assessment dated 20 days after the election of hospice care. Review of RRNHV# 7's patient record revealed an initial bereavement assessment completed 37 days after the election of hospice care. Review of BR# 1's patient record revealed the initial bereavement risk assessment completed seven days after the election of hospice care. Review of BR# 2's patient record revealed the initial bereavement assessment was completed 11 days after the election of hospice care. This was reviewed, discussed, and validated with the Administrator/Director of Patient Care Services.

Observed in Record Review. In 6 of 14 patient records reviewed, During BR#1, BR# 2, D/C# 2, RRNHV# 1, RRNHV# 2, RRNHV# 4's patient records it was noted the organization had not ensured staff followed the organization policy Bereavement Services that included completing an initial bereavement assessment as part of the comprehensive assessment and a post death bereavement risk assessment. For example: review of BR# 1’s patient record revealed a spouse of 62 years. Further review of BR# 1’s patient record revealed no documentation of an initial bereavement risk assessment or post death bereavement risk assessment. Review of BR# 1’s IDG/Plan of care update post death revealed documentation that BR# 1’s spouse was high risk for bereavement. Review of BR# 2’s patient record revealed BR# 2’s revealed no documentation of a post death bereavement risk assessment for BR# 2’s daughter. Review of D/C# 2, RRNHV# 1, RRNHV# 2, and RRNHV# 4’s patient records revealed no documentation of an initial bereavement assessment. Review of RRNHV# 1 and RRNHV# 2’s patient record revealed no documentation of a post death risk assessment. This was reviewed, discussed, and validated with the Administrator/Director of Patient Care Services.

Observed in Record Review. In 1 of 14 patient records reviewed, During RRHV# 1's patient record review it was noted the organization had not ensured the interdisciplinary group reviewed and revised the plan of care no less frequently then every 15 calendar days. For example: review of RRHV# 1's patient record revealed an initial IDG/Plan of care with the subsequent IDG/Plan of Care update 25 days after the initial IDG/Plan of care. Review of the scheduled subsequent IDG dated 10 days after the initial IDG/Plan of care sign in sheet and agenda of patients reviewed, revealed no documentation of HV# 1. This was reviewed, discussed, and validated with the Administrator/Director of Patient Care Services.

Observed in Record Review. In 2 of 2 bereavement patient records reviewed, During BR# 1 and BR# 2's patient records review it was noted the organization had not ensured care, treatment, or services were provided according to the patient's bereavement plan of care. For example: Review of BR# 2’s daughter’s bereavement plan of care revealed the intervention of completing a post death risk assessment. However, review of BR# 2’s patient record revealed no documentation of a post death risk assessment. Review of BR# 1’s daughter and granddaughter’s bereavement plans of care revealed the intervention of completing a post death risk assessment. However, review of BR# 1’s patient record revealed no documentation of a post death risk assessment for either BR# 1’s daughter or granddaughter. This was reviewed, discussed, and validated with the Bereavement Coordinator and Administrator/Director of Patient Care Services.

Observed in Patient Home. In 2 of 3 home visits conducted, During RRHV# 1 and RRHV# 2's home observations it was noted the organization had not ensured it implemented its infection prevention and control activities when doing the following: Cleaning and performing disinfection of medical supplies and devices. For example: during RRHV#1 the nurse surveyor observed the clinician cleaned their equipment with Wet Wipes 70% alcohol. However, after cleaning the equipment they placed it on the top of the nurse bag to dry. During RRHV# 2's home observation the home health aide (HHA) provided a shower in a residential facility. The HHA used the shower chair in the community shower room without disinfecting the shower chair prior to use or after use of the shower chair. The residential facility staff shared that the shower chair was used by multiple residents at the facility. This observation was reviewed and verified with the Administrator/Director of Patient Care Services present during the home visits. Observed in Patient Home. In 1 of 2 home visits conducted, During RRHV# 1's home observation it was noted the organization had not ensured it implemented the infection prevention and control activities as planned. For example: During RRHV# 1's home observation the nurse was observed washing hands in a sink that was almost full of water. The nurse applied soap on two occasions and then when the sink almost overflowed then nurse put one hand into the sink of water and took out the plug then rinsed the hand with water. In addition, during the home observation the nurse removed the gloves and put on a new pair of gloves without performing hand hygiene per organization policy Hand Hygiene. This was reviewed, discussed, and validated with the Administrator/Director of Patient Care Services that was present during the home visit.

Observed in Record Review. In 4 of 14 patient records reviewed, During BR# 1, D/C# 2, RRNHV# 1, and RRNHV# 2's patient record it was noted the organization had not ensured it developed a bereavement plan of care that specified the type of bereavement services to be offered and the frequency of service delivery. For example: review of BR# 1's patient record revealed BR# 1 lived with the spouse of 62 years. Review of BR# 1's IDG/Plan of care update post death revealed BR# 1's spouse was high risk for bereavement. However, review of BR# 1's patient record revealed no bereavement plan of care for BR# 1's spouse. Review of D/C# 2, RRNHV# 1, and RRNHV# 2's the patient records revealed no initial bereavement assessments and no bereavement plans of care. This was reviewed, discussed, and validated with the Administrator/Director of Patient Care Services.

Observed in Record Review. In 1 of 14 patient records reviewed, During RRHV# 1's patient record review it was noted the organization had not ensured the registered nurse prepared complete written patient care instructions for the hospice aide. For example: review of RRHV# 1's patient record revealed RRHV# 1 had bleeding precautions and fall precautions. Review of RRHV# 1's hospice aide written patient care instructions revealed the task of shaving. Further review of the written patient care instructions revealed no documentation of fall precautions, bleeding precautions or directions on what type of razor to use with bleeding precautions. This was reviewed, discussed, and validated with the Administrator/Director of Patient Care Services.

Observed in Record Review. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by the condition level findings at 418.102 as significant issues with the initial and recertification certificate of terminal illness documentation and timely completion; and 418.104, as significant issues with complete and accurate patient records; and 418.64, as significant issues with the Bereavement programs with missing and late initial bereavement assessment, post death assessment, and bereavement plans of care as per polices.

Observed in Record Review. In 2 of 14 patient records reviewed, During RRHV# 1 and RRHV# 3's patient records review it was noted the organization had not ensured the initial certificate of terminal illness written by the Medical Director considered current subjective and objective medical findings and current medication and treatments. For example: review of RRHV# 1's initial CTI revealed documentation Evidence of eligibility: a Face to Face visit was performed during the prior certification period continued to decline was documented. Recertification is in the patient's best interest and is clinically justified. However, RRHV# 1 was a new admission to hospice and in the first benefit period with no documented Face to Face. Review of RRHV# 3's initial CTI revealed documentation Evidence of Eligibility: a Face to Face visit was performed on the following during the prior certification period. Continued decline was documented including: changes in weight as noted by the changes in the MAC along with a decline in functional capacity. Recertification is in the patient's best interest and is clinically justified. However, RRHV# 3 was a new admission to hospice and in the first benefit period with no documented Face to Face. This was reviewed, discussed, and validated with the Administrator/Director of Patient Care Services.

Observed in Record Review. In 2 of 7 patient records reviewed with recertification, During HV# 1, HV# 3, and RRNHV# 7's patient records review it was noted the organization had not ensured the Medical Director signed the certificate of terminal illness (CTI) prior to the recertification. For example: review of RRHV# 1's recertification CTI revealed the verbal order by the RN dated one day after the recertification and Medical Director signed one day after the recertification. Review of RRHV# 3's recertification CTI revealed the verbal order by the RN dated one day after the recertification with the Medical Director signature 34 days after the recertification. This was reviewed, discussed, and validated with the Administrator/Director of Patient Care Services.

Observed in Record Review. In 6 of 14 patient records reviewed, During RRHV# 1, RRHV# 2, RRHV# 3, D/C# 1, D/C# 2, and RRNHV# 6's patient records review it was noted the organization had not ensured it maintained complete and accurate patient records. For example: review of RRHV# 1's patient record revealed six Interdisciplinary group (IDG)/Plan of care updates with inaccurate dates of the actual IDG/Plan of care update meetings. Review of RRNHV# 6's patient record reveled four IDG/Plan of care updates with inaccurate dates of the actual IDG/Plan of care update meetings. Review of RRHV# 2's patient record revealed six IDG/Plan of care updates with inaccurate dates of the actual IDG/Plan of care update meetings. This was reviewed and discussed with the Administrator/Director of Patient Care Services and IT Support that shared the IDG/Plan of care updates schedule was input with the wrong dates. Review of RRHV# 1's patient record revealed a start of care 115 days prior to the surveyor review of the record. Further review of the patient record revealed no documentation of a physician order for hospice evaluation. Upon discovery of no documentation of a referral order the referral order was found in the medical record office and not in RRHV# 1's patient record. Review of RRHV# 1's recertification RN comprehensive assessment revealed documentation that RRHV# 1 had oxygen in the home. Further review of RRHV# 1's patient record revealed RRHV# 1 had not been ordered oxygen and there was no oxygen in the home. Review of RRHV# 3's patient record revealed a recertification certificate of terminal illness with documentation “Evidence of Eligibility: a Face to Face visit was performed on the following during the prior certification period continued decline was documented including: there has been a decline in functional capacity secondary to worsening underlying cardiac disease. Recertification is in the patient's best interest and is clinically justifiable”. However, this was RRHV# 3's second benefit period and review of RRHV# 3's patient record revealed no documentation of a Face to Face. Further review of RRHV# 3's patient record revealed RRHV# 3 was started on oxygen 86 days prior to the surveyor review of the record and RRHV# 3's patient record revealed an oxygen safety risk assessment completed on start of care with documentation RRHV# 3 was not ordered and did not have oxygen in the home. Further review of RRHV# 3's patient record revealed no updated oxygen safety risk assessment to include oxygen equipment safety assessment. Upon discovering the updated oxygen safety risk assessment was not present in the patient record the organization found the updated oxygen safety risk assessment in the medical records office 87 days after oxygen was initiated. Review of D/C# 2's patient record revealed D/C# 2 went to the hospital for a gastrointestinal bleed. Further review of the record revealed documentation D/C# 2 revoked hospice services. However, review of D/C# 2's patient record revealed no documentation of a revocation by the patient. Upon discovery of no documentation of a revocation in the revocation was found in the medical records office 160 days after the dated revocation/discharge from the organization. Review of D/C# 1's patient record revealed a discharge summary with documentation D/C# 1 revoked hospice services. Further review of the record revealed a request for information from a hospice indicating D/C# 1 had transferred to a new hospice. Further review of D/C# 1's patient record revealed D/C# 1 was ordered oxygen 207 days prior to the surveyor review of the patient record. Review of D/C# 1's patient record revealed no documentation of an oxygen safety risk assessment. Upon discovering the patient record had no oxygen safety risk assessment, the organization found the oxygen safety risk assessment in the medical records office 208 days after oxygen was initiated and 42 days after discharge. This was reviewed, discussed, and validated with the Administrator/Director of Patient Care Services. Observed in Record Review. In 2 of 14 patient records reviewed, During BR# 2, and D/C# 2's patient records review it was noted the organization had not ensured documentation in the patient record was entered in a timely manner. For example: review of BR# 2’s patient record revealed a bereavement phone call by the Bereavement Coordinator with documentation a message was left regarding the 30 day follow up on the bereavement plan of care that was documented 203 days after the phone message was left for BR# 2’s daughter. Further review of the record revealed no further follow up from the Bereavement Coordinator. Review of D/C# 2's patient record revealed the last SN visit regarding calling 911 documented 37 days after the date of the visit. This was reviewed, discussed, and validated with the Administrator/Director of Patient Care Services

Observed in Record Review. In 2 of 14 patient records reviewed, During RRHV# 1 and D/C# 2's and patient records review it was noted the organization had not ensured all entries into the clinical record were appropriately authenticated with signature and title (occupation). For example: review of the patient records revealed one clinician's electronic signature and title Marketing/SN without indicating the occupation LPN (Licensed Practical Nurse). This was reviewed, discussed, and validated with the Administrator/Director of Patient Care Services.