Every finding on record at Rejuvenate Hospice Care, Inc.

Observed in HR File Review. In 1 of 1 HR files reviewed, the organization did not provide Infection control and Blood Borne Pathogens education and training. For example, in HR file #1 there was no evidence in the HR file Infection control and Blood Borne Pathogen education and training had been provided. This was validated and reviewed with the Alternate Administrator.

Observed in HR File Review. In 1 of 1 HR files reviewed, the organization did not ensure the clinician had the required education hours. For example, in HR file #1 there was no evidence in the HR file the Hospice Aide completed 12 hours of education hours as required annually for 2024.

Observed in Leadership Session. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by issues identified with record of care and leadership resulting in condition level findings at 418.100 and 418.104.

Observed in Record Review. In 1 of 1 HR files reviewed, the organization did not assess the annual competency of the clinician. For example, in HR File #1 the Hospice Aide did not have a completed annual competency as required by the organization's policy. This was validated and reviewed with the Alternate Director of Patient Care Services.

Observed in Record Review. In 4 of 4 patient records reviewed, the organization did not show an audit trail of the revocation documentation upon request. For example, in RRDC #1, 2, 3, and 4 the Surveyor was handed paper revocation forms for each patient despite the organization's use of electronic medical records and denial of any paper charts. This was validated and reviewed with the Alternate Director of Patient Care Services and the Office Manager.

Observed in Record Review. In 3 of 10 patient records reviewed, it was noted that the patient record was inaccurate or contained errors. For example in record RRNHV#1 on the day of admission to hospice there was an order for a heparin flush to the patient's Port a Cath, however there was no documentation that the flush had been completed and no documentation in the initial assessment of the patient having a Port a Cath in place. In records RRBR#1 and #2 there was no documentation of the LVN contacting the physician after the patient's death. The organization's policy Death At Home stated the nurse will notify the attending physician of the patient's death. It will be the attending physician's responsibility to pronounce death. During discussion with the LVN about death visits, she stated that after checking VSs she contacts the physician by phone. However there was no documentation of these conversations. This was confirmed with the DON present.

Observed in Record Review. In 10 of 10 patient records reviewed, it was noted that the written plan of care was not individualized. For example in record RRNHV#1 all of the goals timeframes were dated the next recertification date in 3 months. Including Resolve pain with medications ordered. Teach Pt/Family/PCG on immediate use, efficacy and precautions. and Pt/pcg will verbalize/express understanding of medication /treatment orders and side effects. This POC also included the intervention Oxygen as ordered via ______ at ______L/min . In record RRNHV#2 all of the goals timeframes were dated the next rectification date in 3 months, including Pt/pcg will verbalize/express understanding of medication /treatment orders and side effects. Records RRNHV#3 to #7 and RRHV#1 to #3 all goals timeframes were the next recertification date and included similar goals to those quoted. This was confirmed and discussed with the DON and Administrator present.

Observed in Record Review. In 2 of 10 patient records reviewed, it was noted that the plan of care did not include all information of medications necessary to meet the patient's needs. For example, in record RRNHV#4 the POC included Advil and Tylenol extra strength both as needed for pain with no further direction such as which medication to use first. In record RRNHV#7 the POC included Tylenol, Ibuprofen, Lidocaine patch, and Tramadol all as needed for pain with no further direction. This was confirmed and discussed with the Administrator and DPCS.

Observed in HR File Review. In 1 of 9 HR files reviewed, it was noted that the organization was unable to provide the HR file for the hospice aide that documented providing patient care and as a result the communication evaluation items were not evaluated. This was discussed with the Administrator/DPCS the file was requested from. Observed in HR File Review. In 1 of 9 HR files reviewed, it was noted that the organization was unable to provide the HR file for the hospice aide that documented providing patient care and as a result there was no supervisor evaluations . This was discussed with the Administrator/DPCS the file was requested from. Observed in HR File Review. In 1 of 9 HR files reviewed, it was noted that the organization was unable to provide the HR file for the hospice aide that documented providing patient care and as a result there was no evaluation of the subject areas identified. This was discussed with the Administrator/DPCS the file was requested from.

Observed in HR File Review. In 1 of 9 HR files reviewed, it was noted that the organization had not performed the competency evaluation of the hospice aide. For example when the HR file for the HHA/hospice aide was requested the organization was unable to provide the HR file or any documentation. This was discussed with the Administrator/DPCS the file was requested from.

Observed in HR File Review. There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by...condition level findings at 418.114 human resources and 418.54 records.

Observed in HR File Review. During review of the HR files it was noted that the LVN and RN files did not include education and training for death visits. This was confirmed and discussed with the DPCS present. Observed in HR File Review. In 2 of 8 HR files reviewed, it was noted that the staff competence was not assessed and documented annually as required by the organization's policy. For example, in the Spiritual Counselor/Bereavement Coordinator file and the Administrator/DPCS file there were documents titled Annual Competencies with boxes checked, however the documents were not signed by the staff member or an agency representative and were not dated. This was confirmed with the Administrator present.

Observed in HR File Review. In 1 of 9 HR files reviewed, it was noted that the organization was unable to provide the HR file for the hospice aide that documented providing patient care and as a result there was no verification or documentation of the staff credentials. This was discussed with the Administrator/DPCS the file was requested from.

Observed in Record Review. In 5 out of 11 records reviewed, it was observed that the organization did not inform the patient in writing of their financial obligation prior to beginning services. In HV#3/RR#3, RR#4, and RR#7's records review, the surveyor noted that the payment section was blank on the consent form. This was reviewed and discussed with Administrator and Administrator Designee.

Observed in Record Review. In 2 out of 11 patient records reviewed, Spiritual Counselor failed to complete their initial assessment within 5 days after the election of hospice. During RR#8's patient record review, it was noted that the Spiritual Counselor's initial assessment was completed on day 13. This was reviewed and discussed with Administrator Designee.

Observed in Patient Home. In 1 out of 3 home visits conducted, the surveyor noted that staff failed to perform hand hygiene consistent with policy. For example, in HV#2 the aide was observed using dishwashing soap and paper towels provided by the Caregiver instead of using the supplies provided by the organization as per policy. Aide also turned of the faucet with her bare hands instead of using a paper towel. This was reviewed and validated with the Administrator and the Administrator Designee.

Observed in Record Review. In 1 out of 11 patient records reviewed, the CTI did not consider all of the required elements. In HV#2/RR#2's record review, the surveyor noted that BP2 CTI did not contain a written narrative from the physician. This was reviewed and discussed with the Administrator Designee.

Observed in Patient Home. In 1 out of 2 home visits conducted with oxygen therapy, the surveyor noted that the organization did not manage safety and security risks. For example, in HV# 3/RR#3, the surveyor observed one oxygen tank standing upright unsecured. Education had not been provided during visit to reinforce the safety of securing the tanks. The DME company was notified. This was confirmed and validated with the Administrative Designee.