Every finding on record at Range Regional Health Services

Observed in Record Review. In 5 of 5 patient records reviewed, During the record reviews, in 5 of 5 in- home hospice patient records, the Hospice surveyor noted that the organization was using a list of protocols signed by the MD but not individualized. For example, the home care protocol list included may initiate of OTC stool softeners, stimulants, laxatives, osmotics and/or magnesium sulfate for the prevention or relief of constipation, per package instructions. SN may provide digital stimulation, manual removal of stool, and/or administration of fleets or tap water enema, as need for signs/symptoms of constipation PRN. May initiate, increase or decrease frequency of all hospice discipline services dependent on client need/condition and/or family request, PRN. If client is having difficulty swallowing, may change route of administration from oral to injection or rectal, PRN. Inset foley catheter, irrigate or flush as needed, May insert 16 fr 5 CC catheter for s/sx urinary retention. May irrigate with 60-120 cc's sterile NS or sterile H2O. May use Lidocaine Urojet with insertion. May use Coudet if unable to insert foley. Change PRN for loss of patency. Wound care: cleanse with soap and water, as needed. May dress open areas with gauze, transparent dressing, hydrocolloid, or composite dressing. May use foams or alginate to contain drainage, change weekly and PRN, May use barrier cream PRN. Port flush with non-coring needle, flush with 10 cc's NS and 5 CC heparin/units 100. This was validated in a discussion with and observation by the Director of Home Care Quality. Observed in Record Review. In 10 of 10 patient records reviewed, During the record reviews, in 5 of 5 facility records, the Hospice surveyor noted that the organization was using a list of protocols signed by the MD but not individualized. For example, the facility protocol list included may initiate of OTC stool softeners, stimulants, laxatives, osmotics and/or magnesium sulfate for the prevention or relief of constipation, per package instructions. SN may provide digital stimulation, manual removal of stool, and/or administration of fleets or tap water enema, as need for signs/symptoms of constipation PRN. May initiate, increase or decrease frequency of all hospice discipline services dependent on client need/condition and/or family request, PRN. If client is having difficulty swallowing, may change route of administration from oral to injection or rectal, PRN. Inset foley catheter, irrigate or flush as needed, May insert 16fr 5CC catheter for s/sx urinary retention. May irrigate with 60-120 cc's sterile NS or sterile H2O. May use Lidocaine urojet with insertion. May use Coudet if unable to insert foley. Change PRN for loss of patency. This was validated in a discussion with and observation by the Director of Home Care Quality.

Observed in Record Review. In 3 of 3 patient records reviewed, During the record review, in 3 of 3 records reviewed, the Hospice surveyor noted that the plans of care were not individualized with appropriate frequencies, time frames and measurable goals. For example, HV1, HV 2 and HV 3, the goal dates were all at the end of the certification in 90 days instead of the next IDT date. In addition the PRN visit number for SN was listed as 10 for all 3 records instead of 2-3 which would cover a 2 week period. This was validated in a discussion with and observation by the Director of Home Care Quality.

Observed in Individual Tracer. In 1 of 3 home visits conducted, During HV 1 the Hospice surveyor noted that the aide did not change her gloves after changing the bath water. The organization policy for Hand Hygeine Ver 9 Ref # 5204, number F states that hand hygeine is performed when changing from dirty to clean procedures. This was validated in a discussion with and observation by the Director of Home Care Quality. Observed in Individual Tracer. In 2 of 2 home visits conducted, During HV 2 the nurse did not follow the organization Bag technique Policy Ver 3, Ref # 5389, III which stated bas without wheels should not be placed on the floor with or without a barrier. The nurse placed her backpack, without wheels, on a barrier on the floor. During HV 3 the nurse did not follow VII, which states that supplies needed will be removed form the bag and placed on a barrier. The nurse place her equipment on the bedside table without a barrier. This was validated in a discussion with and observation by the Director of Home Care Quality.

Observed in Record Review. In 2 of 4 records reviewed with aide services, During the record review, in 2 of 4 records with aides, the Hospice surveyor noted that the organization was not providing aide supervision every 14 days. For example, in HOS HV 1 there were 15 days between supervisory visits and in HOS RR2 there were 21 days between supervisory visits. This was validated in a discussion with and observation by the Director of Home Care Quality.

Observed in Record Review. The Hospice surveyor noted that leaders review, approve, and manage the implementation of policies and procedures that guide and support patient care, treatment, or services. The leadership did not provide oversight to manage 418.56. This was validated in a discussion with home care leadership.

Observed in Record Review. In 1 of 7 active patient records review, During HOS RR# 1's patient record review it was noted the organization had not ensured the initial bereavement assessment was completed. For example: review of HOS RR# 1's MSW initial assessment revealed no documentation of an initial bereavement assessment. This was reviewed, discussed, and validated with the RN Case Manager and the Quality and Compliance Coordinator.

Observed in Record Review. In 7 of 7 active patient records reviewed, During HOS HV# 1, HOS HV# 2, HOS HV# 3, HOS RR# 1, HOS RR# 2, HOS RR# 3, and HOS RR# 4's patient records review it was noted the organization had not ensured the plans of care were based on the patient's goals and the time frames, settings, and services required to meet those goals. For example: review of HOS HV# 1's plan of care revealed all the goals with the same time frames to include Caregiver will acknowledge understanding of hospice contact information [90 days]; Caregiver will receive adequate support from team for patient care [90 days]; Patient symptoms will be managed [90 days]. Review of HOS HV# 2's patient record revealed HOS HV# 2 had right chest wall Pleurix drain. Review of HOS HV# 2's plan of care revealed the intervention Teach caregiver how to properly drain Pleurix and associated dressing change. Further review of the plan of care revealed no goals for the Pleurix drain. Review of HOS HV# 3's plan of care revealed all goals with the same time frames to include Spiritual needs met [90 days]. Review of HOS RR# 1's plan of care revealed all goals with the same time frames that included Patient and family will have a HCAD (Health Care Advanced Directive) [90 days]. Review of HOS RR# 2's plan of care revealed all goals with the same time frame to include Patient will maintain score of ____ or less per patient preference [90 days]. Review of HOS RR# 3 and HOS RR# 4's plans of care revealed all goals with the same time frames. This was reviewed, discussed, and validated with the RN Case Manager and Quality and Compliance Coordinator.

Observed in Record Review. In 7 of 7 patient records reviewed, During HOS HV# 1, HOS HV# 2, HOS HV# 3, HOS RR# 1, HOS RR# 2, HOS RR# 3, and HOS RR# 4's patient records review it was noted the organization had not ensured the plan of care included medications and treatments necessary to meet the patient's needs. For example: review of HOS HV# 2's plan of care revealed a Pleurix drain with assessment of drainage and to assist family with drainage as needed with no frequency of drainage, parameters for fluid removal, or dressing change directions. Further review of HOS HV# 2 and HOS HV# 1’s plans of care revealed wound care orders with the initiation date of start of care that included the standing orders “wound care cleanse with soap and water; as needed; may dress open areas with gauze, transparent dressing, hydrocolloid, or composite dressing. Change PRN for loss of patency. May use foam or alginate to contain drainage, to change weekly and PRN for loss of patency.” Review of HOS HV# 1, HOS HV# 3, HOS RR# 1, HOS RR# 2, HOS RR# 3, and HOS RR# 4's patient records review revealed the standing order “oxygen Via Nasal Canula device; Administer 2-4 liters per minute inhaled Continuous for shortness of breath; may initiate oxygen for symptoms of respiratory distress. However, review of the patient’s records revealed the patients did not have oxygen in the home. This was reviewed, discussed, and validated with the RN Case Manager and the Quality and Compliance Coordinator.

Observed in Patient Home. In 3 of 3 home visits conducted, During HOS HV# 1, HOS HV# 2, and HOS HV# 3's home observations it was noted the organization had not ensured the organization's Bag Technique, Home Care and Hospice REF# 5389, Ver 2 policy that included the bag be placed on a clean dry surface with a waterproof barrier beneath it. Avoid upholstered furniture and visibly soiled areas. For example: during HOS HV# 1's home observation the RN was observed putting a barrier on the floor and placing the nurse bag on the floor. During HOS HV# 2's home observation the RN was observed putting a barrier on the floor and placing the nurse bag on the floor. During HOS HV# 3's home observation the RN was observed putting a barrier on the Skilled Nursing Facility floor and placing the nurse bag on the floor. This was observed, discussed, and validated with the RN Case Manager and the Quality and Compliance Coordinator. Observed in Patient Home. In 1 of 1 Home visits conducted with vital sign equipment cleaned, During HOS HV# 1's home observation it was noted the registered nurse had not followed the organization’s Bag Technique, Home Care and Hospice REF# 5389, Ver 2 policy that included, “If re-usable equipment is used during patient care, disinfect the equipment using approved product for require wet time and allow to dry on a clean barrier prior to placing back in bag”. For example: during HOS HV# 1’s home observation the RN was observed wiping down the re-useable vital sign equipment and immediately placed it into the nurse bag without allowing it to air dry. This was observed, discussed, and validated with the RN Case Manager and the Quality and Compliance Coordinator. Observed in Patient Home. In 2 of 3 home visits conducted, During HOS HV# 1 and HOS HV# 2's home observation it was noted the organization had not ensured staff followed the organization's Hand Hygiene - Hand Washing REF# 5204, Ver 6 policy that included performing hand hygiene prior to entering the nurse bag. For example: during HOS HV# 1's home observation the RN was observed with gloves cleaning the vital sign equipment and placing the stethoscope and B/P cuff into the nurse bag without performing hand hygiene prior to entering the bag. during HOS HV# 2's home observation the RN was observed with gloves cleaning the computer placed the computer into the nurse bag without performing hand hygiene prior to entering the bag. This was observed, discussed, and validated with the RN Case Manager and the Quality and Compliance Coordinator. HCW are expected to perform hand hygiene before entering

Observed in Record Review. In 2 of 3 active patient records review with home health aide services, During HOS RR# 1 and HOS RR# 2's patient records review it was noted the registered nurse had not prepared complete written patient care instructions for the hospice aide. For example: review of HOS RR# 1's patient record revealed HOS RR# 1 had a pressure ulcer on the coccyx with a wound dressing in place. Review of HOS RR# 1's home health aide written instructions revealed the task of a shower or a bed bath with no written instructions regarding how to keep the wound dressing dry or what to do if the wound dressing got wet. Review of HOS RR# 3's patient record revealed HOS RR# 3 used a standing lift for transfers. Review of the home health aide written instructions revealed bed to chair transfer with no written instructions on using the transfer equipment. This was reviewed, discussed, and validated with RN Case Manager and the Quality and Compliance Coordinator.

Observed in Record Review. During records review it was noted the organization had not ensured the policies and procedures that guide and support patient care, treatment, or services were followed. For example: the governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews:  - §418.100 and §418.56.

Observed in Patient Home. In 3 of 3 home visits conducted, During HOS HV# 1, HOS HV# 2, and HOS HV# 3's home observations it was noted the organization had not ensured the patient record contained information that reflected the patient's care, treatment, or services. For example: review of HOS HV# 1's medication profile revealed Tylenol 325 mg 1-2 tablets as needed and Melatonin 10mg tablet. During the review of the medications, it was noted the caregiver was administering Tylenol 500 mg 1 tablet as needed and Melatonin 5mg one tablet. Review of HOS HV# 2's patient record revealed two different titrations as needed orders for lorazepam for anxiety with different frequencies of administration. Review of HOS HV# 3's medication profile revealed two different titrations as needed orders for Morphine Sulfate for pain and dyspnea. This was reviewed, discussed, and validated with the RN Case Manager and the Quality and Compliance Coordinator.

Observed in Document Review. During HOS HV# 2's home observation and review of the Admission packet it was noted the organization had not ensured it provided a copy of its written policies and procedures on the management and disposal of controlled medication to the patient or the patient's representative and family. For example: review of HOS HV# 2's home folder and the Admission packet revealed no policy on the disposal of controlled medication. This was observed, discussed, and validated with RN Case Manager and the Quality and Compliance Coordinator.