Every finding on record at Providence Hospice, Inc

Observed in Individual Tracer. A review of 3 of 3 individual tracers, revealed that the organization did not ensure all entries in the medical record were documented accurately. For example, during a review of the informed consent documents for RRHV#1, RRHV#2, and RRHV#3, it was noted that the patient chose the organization's medical director as the attending physician. However, a review of the certification statement(s) revealed that a different physician signed the document(s) as the attending physician. This observation was reviewed with the Administrator and the Director of Patient Care services.

Observed in Record Review. In 1 of 10 patient records reviewed, it was noted that the organization did not ensure the plan of care goals included outcome measures for specific care activities, For example, during a review of the medical record for RRNHV#3, the comprehensive assessment included a description of a stage 2 pressure ulcer at the sacral area. The plan of care did not include interventions related to wound care and a goal statement to evaluate the response to care, treatment, and services related to wound care interventions. This observation was reviewed with the Administrator and the Director of Patient Care Services.

Observed in Record Review. In 2 of 4 patient records reviewed, for patient's receiving Hospice Aide services, it was noted that the organization did not ensure Hospice Aide visits were completed in accordance with the plan of care. For example, during a review of the medical record for RRNHV#1, the plan of care included an order for Hospice Aide visits 2 times per week. The Hospice Aide performed visits 3 times per week starting the 6th week of services during the first benefit period. Hospice Aide visits continued to be performed 3 times per week during the 2nd benefit period. Example #2: During a review of the medical record for RRNHV#5, the plan of care included an order for Hospice Aide visits 2 times per week. The Hospice Aide performed visits 3 times per week during week #2, and week #4 of services. This observation was reviewed with the Administrator and the Director of Patient Care Services.

Observed in Patient Home. In 1 of 1 home visits conducted, the organization did not implement infection prevention and control activities it had planned to minimize, reduce, or eliminate the risk of infection. In HV#1, The RN did not clean the used care equipment (BP monitor, stethoscope, thermometer, and pulse oximeter) and perform hand hygiene prior to placing items back in bag. This practice was not in compliance with the organization's policy and procedure for bag technique. This was reveiwed and verified with the Administrator and Director of Patient Care Services.

Observed in HR File Review. In 1 of 2 HR files reviewed, the staff competence was not initially assessed and documented as part of orientation. In HR#2, it was noted the initial competencies for the hospice aide were indicated as assessed verbally, with no direct observation by the RN of tasks/care performed except for handwashing. This was reveiwed and verified with the Administrator and Director of Patient Care Services.