Every finding on record at Pure Soul Hospice, Inc

Observed in Record Review. In 12 of 12 patient records reviewed, the Surveyor noted Patient Plan of Care (POC) goals had not been measurable, updated and/or with an appropriate time frame. Examples include: Patient`s pain will be maintained at a 2/10 or less with use of medication and non pharmacological interventions within next 7 days (carried through the patients entire episode of care); Patient will tolerate a mechanical soft consistency diet and will be free from signs and symptoms of aspiration within next 7 days; Patient will be free from any signs of skin breakdown due to bladder incontinence within next 7 days; Patient will be able to rest comfortably without exhibiting signs and symptoms of anxiety, agitation, or sad mood within next 7 days; Patient`s PCG will verbalize understanding of fall precautions and oxygen use and safety interventions by end of SN visit today (repeated several times on the patients care plan over several IDG meetings). This was validated with the DPCS and the QAPI RN.

Observed in Record Review. In 5 of 12 patient records reviewed, the Surveyor noted not all conditions related to the palliation of patient care had been on the Plan of Care (POC) and orders for wound care had been incomplete. For example, RRHV #1, the patient had a diagnosis of end stage CHF, however, End Stage CHF had not been on the patient's POC with goals and interventions. RRHV #2, the patient had been on Ofloxacin 0.3 % drops to bilateral eyes for infection and the PCG stated the patient had been using for 2 weeks; however this had not been included on the patient's medication profile. In RRNHV #4, the patient had orders for wound care; however, the order did not specify who was to complete the wound care. RRNHV #5, the patient had a diagnosis of Congestive Heart Failure and shortness of breath, but these had not been included on the POC. RRNHV #8 the patient had been experiencing dyspnea and on home oxygen; however, this had not ben included on the POC. This was validated with the DPCS and the QAPI RN.

Observed in Patient Home. In 1 of 3 home visits conducted, the Surveyor noted the MSW in RRHV #2 had not followed the HCO Bag Technique Policy No. 9-014.1 which directs the clinician to place the bag on a clean dry surface that can be easily disinfected in the home. The MSW had been observed to set her clinical bag on the patient's couch without a barrier and her bag remained open throughout the visit. This was validated with the QAPI and the DPCS.

Observed in Patient Home. In 1 of 1 home visits conducted, During HV#1 it was noted the SN did not disinfect the stethoscope, BP cuff and pulse oximeter prior to returning to clinical bag per agency policy Bag Technique Policy #9-014. Observed in Patient Home. In 1 of 1 home visits conducted, During HV#1 it was noted the SN did not follow the organization's bag technique policy ( Bag Technique, Policy # 9-014.  The nursing bag remained on the patient's floor without a barrier throughout the visit.  The SN entered the bag several times while providing patient care without removing her gloves and disinfecting her hands.

Observed in Infection Control Tracer. The organization's written infection prevention and control plan did not include a measurable goal limiting the spread of infections associated with the use of medical equipment, devices, and supplies. Observed in Infection Control Tracer. During review of the organization infection control goals it was noted lack of a measurable goal that included limiting unprotected exposure to pathogens. Observed in Infection Control Tracer. The organization's written infection prevention and control goals lacked a measurable goal to include limiting the spread of infections associated with procedures.

Observed in Record Review. During Bereavement RR#1, it was noted the discharge summary in the EMR was blank.