Every finding on record at Quivira Healthcare LLC

It is required that the patient’s pain is assessed as part of a comprehensive assessment. 1. Assessment of pain in children and adolescents is conducted with consideration of age and neurocognitive development. The documented assessment of the patient’s pain includes: 1. History of pain and its treatment, both pharmacological and non-pharmacological; 2. Use of a standardized pain assessment tool appropriate to the patient’s developmental and cognitive status; 3. Characteristics of the pain, including: a) Location, frequency, and intensity; b) How pain impacts the patient’s ability to engage in usual activities and function (e.g., appetite, sleeping); 4. The patient’s/family’s goals for pain management and their satisfaction with the current level of pain control. This standard was not met as evidenced by clinical record review and interview. 1 of 8 (13%) records reviewed revealed the hospice did not ensure the clinical record contained a comprehensive pain assessment. Record #42837: The initial assessment dated 11/12/2021 documented that the patient "did not have pain" and a comprehensive pain assessment was not completed. In an interview with the RN on 12/9/2021, it was stated that the daughter told the nurse that the patient was not having pain, so no further assessment was completed. Documentation was present that the daughter reported on 11/19/2021 that the patient flinched with pain when care was being provided. Tramadol 50 mg 1/2 tab po 2 6 hrs prn was ordered for pain. The Director of Patient Care Services was interviewed on 12/9/2021 and indicated that the pain assessment was not included in the clinical record and there was no additional information to provide.

It is required that each patient’s individualized written plan of care reflects patient and family goals; and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments; This standard was not met as evidenced by review of records and interview. 2 of 8 (25%) clinical records reviewed failed to include patient and family goals and interventions in the Plan of Care (POC), based on the problems identified in the comprehensive assessments. Record #53814 was reviewed. The goal for the patient was "patient verbalizes tolerance to pulse oximetry procedure". This goal did not reflect the patient and family's goals. In an interview with the Director of Patient Care Services, it was stated that this goal was not individualized to the patient. Record #42837 was reviewed. The RN initial assessment dated 11/12/2021 documented the patient had 3+ edema in bilateral lower extremities. The POC did not identify planned interventions to address the edema. The Director of Patient Care Services was interviewed on 12/9/2021, and confirmed the POC did not include the required elements. No additional information was provided by the agency.

It is required that the hospice follows accepted standards of practice to prevent the transmission of infections and communicable disease, including the use of standard precautions, such as Hand hygiene; This standard was not met as evidenced by observation, and interview and record review. 1 of 3 (33%) home visits revealed the hospice did not ensure adherence to agency infection prevention and control policies and procedures. During observation of Patient #40181 on 12/9/2021 at 5:10pm, RN #54802 washed his hands and entered the patient's room. The RN assessed the patient's blood pressure and placed his hands into the visit bag to obtain the pulse oximeter. The RN had not decontaminated his hands before he reached into the visit bag after touching the patient. The Administrator and Regional Administrator were interviewed on 12/10/2021 and both agreed the staff member did not follow the agency policy and procedures. Agency policy "Hand Hygiene" revised April 2017 , stated hand decontamination with an alcohol-based hand rub is required "after contact with the patient's intact skin (when taking a pulse, blood pressure, or lifting a patient).

It is required that the hospice assesses the skills and competencies of all individuals providing care, including volunteers providing services and, as necessary, provides in-service training and education programs where required. This standard was not met as evidenced by review of personnel records and interview. 1 of 8 (13%) personnel records reviewed revealed the hospice did not ensure personnel records contained competencies of all individuals providing care. Record #92116 was reviewed and identified the Master of Social Work (MSW) was hired on 8/25/2021 and performed a visit on 10/9/2021. The MSW competency was completed on 11/7/2021. This hospice did not complete the competency prior to providing care as per agency policy "Competency Based Orientation" which stated, "Hospice ensures that the competency of all personnel is assessed on hire, prior to providing care to hospice patients.". The Administrator was interviewed 12/9/2021 and agreed the hospice did not follow agency policy and procedures for assessing competencies of all individuals providing care.