Every finding on record at Premier Hospice, Inc

Observed in Record Review. In 1 of 11 patient records reviewed, the agency failed to perform a full bereavement assessment within 5 days of admission to hospice. In RR#2 both an MSW and spiritual care assessment were done as part of the comprehensive assessment but the only bereavement assessment documented was the screening by the RN. This was validated with the DPCS.

Observed in Record Review. In 4 of 11 patient records reviewed, the plan of care failed to identify patient and family goals based on identified problems. In HV#1 and HV#2 the plan of care failed to address all of the problems and issues identified in the comprehensive assessment. Since the plan of care did not identify all patient specific problems there were no goals documented for those problems. In RR#2 and RR#4 all goals had the same long term target date thereby failing to indicate which goals should be met in the short term in order to maintain patient safety. This was validated with the DPCS.

Observed in Record Review. In 6 of 11 patient records reviewed, the plan of care did not address all of the issues identified in the comprehensive assessment. In HV#1 weight loss, potential for skin breakdown, aspiration risk, fall risk were identified in the initial comprehensive assessment but not addressed in the plan of care. In HV#2 the plan of care did not address prevention of skin breakdown with a high skin risk, or preventing aspiration. in addition the plan of care was not updated by the IDG when the patient's condition changed. For example, the patient developed a coccyx wound and care was provided but the plan of care was not updated to include specific orders prescribing the wound care. Nursing notes indicated that wound care orders were received but the was no documentation that the orders were added to the plan of care or sent to the physician and IDG for approval. In HV#3 the patient was assessed to be at high risk for falls but fall prevention was not on the plan of care. RR#2 failed to plan for an assessed high risk for skin breakdown. In a similar fashion RR#3, RR#4 failed to address all patient issues identified in the intial comprehensive assessment.

Observed in Record Review. In 2 of 11 patient records reviewed, the agency failed to deliver care and services according to the plan of care. In HV#1 the plan of care called for aide visits twice a week but aide visits were consistently provided three times per week. In HV#2 SN visit frequency was ordered at two times per week. There were multiple weeks in which only 1 nursing visit was made per week without explanation in the record. This was validated with agency leaders.

Observed in Patient Home. In 2 of 3 home visits conducted, staff failed to perform hand hygiene consistent with policy and CDC guidelines. In HV#1 and HV#2 the nurse failed to do hand hygiene with every glove change as required by CDC guidelines. This was validated with the nurse.

Observed in HR File Review. In 3 of 7 HR files reviewed, the agency failed to document ongoing assessment of clinical competencies at least once every 3 years. In HR#2 for a spiritual counselor, HR#3 for the DPCS, and HR#6 for the MSW intial competencies were documented but no ongoing competencies were documented in the HR file. This was validated with agency leadership.

Observed in Record Review. In 2 of 3 patient records reviewed, for patients discharged alive there was no documentation that a discharge summary was offered to the primary physician or other professional who would be providing care after hospice services ended. In RR#4 for a revocation and RR#5 discharged for extended prognosis, a discharge summary was written but there was no documentation that it was shared with or offered to other providers. This was validated with agency leadership.