Every finding on record at Relief Hero Palliative Inc

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 document review, interview and observation. In 2 of 2 (100%) home visit observations revealed the agency did not ensure the staff followed the hand hygiene policy. DOCUMENT 2: Agency Policy: Hand Hygiene (xxx) 041321 Hospice – (xxxx) stated in part, "Decontaminate hands after contact with a client's intact skin (e.g., when taking a pulse or blood pressure, and lifting a client. Decontaminate hands after contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings if hands are not visibly soiled. Decontaminate hands after removing gloves and between glove changes." HOME VISIT 1: During the home visit (Clinical Record 1) on 02/19/2025 with the Registered Nurse (RN) (Personnel Record 6), the RN was observed changing the gloves without decontaminating the hands. HOME VISIT 2: During the home visit (Clinical Record 2) on 02/19/2025 with the Hospice Aide (HA) (Personnel Record 9), the HA was observed changing the gloves during patient care without decontaminating the hands. During a joint document review and interview on 02/19/2025, the Alternate Director of Nursing agreed the staff did not follow the hand hygiene policy.

It is required that a hospice aide provide services that are included in the plan of care. This standard was not met as evidenced by clinical record review, interview and observation. In 1 of 2 (50%) clinical records reviewed of patients receiving hospice aide services revealed the agency did not ensure that the hospice aide provided services included in the plan of care. HOME VISIT 2: The Hospice Aide Plan of Care dated 02/14/2025 documented Bed Bath every visit. During the home visit (Clinical Record 2) on 02/19/2025 with the Hospice Aide (HA) (Personnel Record 9), the HA was observed giving the patient a shower using a shower chair. The Hospice Aide Visit note dated 02/19/2025 documented "completed" for Bed Bath every visit. During a joint clinical record review and interview on 02/20/2025, the Alternate Director of Nursing confirmed that the hospice aide did not provide services included in the plan of care.

It is required that hospice aides must report changes in the patient’s nursing needs to a registered nurse as the changes relate to the plan of care and any quality assessment and improvement activities. The hospice aide must also complete appropriate records of service, including the report of changes in the patient’s needs. Hospice aide documentation complies with hospice policies and procedures. This standard was not met as evidenced by clinical record review and interview. In 1 of 2 (50%) clinical records with hospice aide services reviewed revealed that the agency did not ensure the hospice aide notified the registered nurse of the changes in the patient’s plan of care. CLINICAL RECORD 2: The Hospice Aide Plan of Care dated 02/14/2025 documented Bed Bath every visit. During the home visit (Clinical Record 2) on 02/19/2025 with the Hospice Aide (HA) (Personnel Record 9), the HA was observed giving the patient a shower using a shower chair. The Hospice Aide Visit note dated 02/19/2025 documented "completed" for Bed Bath every visit. The documentation lacked notifying the registered nurse of changes to the plan of care. During a joint clinical record review and interview on 02/20/2025, the Alternate Director of Nursing confirmed that the hospice aide documentation lacked notification to the registered nurse of the changes in plan of care.

It is required that each patient’s individualized written plan of care identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by review of clinical records and interview. In 2 of 6 (33%) records reviewed revealed that Plan of Care (POC) lacked evidence of all problems with associated interventions and goals as identified in the comprehensive assessment. Record # 94616 : The Initial Assessment completed on 2/25/22 identified the problems of potential for skin breakdown, potential for aspiration and dysphagia. The POC lacked evidence of these identified problems with associated interventions and goals. Record # 47382 : The Initial Assessment and POC completed on 2/14/22 provided diagnoses of Heart Failure and Malnutrition. The POC lacked interventions and goals supporting the primary and secondary diagnosis. Interview was conducted with Director of Nursing (DON) on 3/31/22 during a joint review of the clinical records who stated that the POC's lacked evidence of the interventions and goals related to problems identified.

It is required that bags used to carry medical equipment (e.g., BP cuff) or supplies into or out of the care environment are transported and used in a manner consistent with organizational policy to prevent the spread of infections and communicable diseases. This standard was not met as evidenced by observation and document review. In 1 of 3 (33 %) home visits observed identified an infection control break related to bag technique. Agency policy titled Infection Control (No Date) stated in part " Place the bag on a clean surface in the home with a barrier to be placed under the bag." Record # 66375; during a home visit conducted on 3/31/22 during observation of Chaplain (record # 17184) an infection control break was identified related to bag technique. The employee placed his back pack on the floor without using a barrier.

It is required that the hospice medical director, physician employees, and contracted physician(s), in conjunction with the patient’s attending physician, are responsible for the palliation and management of the terminal illness as well as conditions related to the terminal illness. If the attending physician is unavailable, the medical director, contracted physician, and/or hospice physician employee is responsible for meeting the medical needs of the patient. This standard was not met as evidenced by document review and interview. The staff list reviewed lacked evidence of an Associate Medical Director. The Administrator stated in interview on 3/30/22 that the agency had not yet secured an Associate Medical Director.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary. This standard was not met as evidenced by a review of clinical records, documents and interview. In 1 of 1 (100%) of records reviewed for patients discharged live from the agency (Out of 6 total records reviewed) lacked documentation that the discharge summary was forwarded to the physician. Agency policy titled Discharge From Hospice Care (No Date) stated in part " Provide a copy of the discharge summary and, if requested, a copy of clinical record to attending physician, if any, and other service providers who will provide care, treatment, or services to the patient." Record # 47382: Review of discharge summary note dated 2/24/22 lacked evidence that a copy of the discharge summary was provided to attending physician. The Director of Nursing stated in interview during a joint review of the clinical record on 4/1/22 that the record lacked evidence that the discharge summary had been forwarded to the attending physician.

It is required that when controlled medications are first ordered, a copy of the hospice’s written policies and procedures for the management and disposal of controlled medications is provided to the patient or family or patient’s legal representative(s). The Interdisciplinary Group ensures that the safe use and disposal of controlled drugs is understood and documents in the patient record that the policies and procedures for managing and disposing of controlled medications is provided and discussed. This standard was not met as evidenced by a review of documents, clinical records, and interview. In 1 of 1 (100 %) of records reviewed for patients with ordered controlled substances lacked evidence of documentation of drug disposal as per agency policy. Agency policy titled Controlled Drugs Safe Use and Disposal (No Date) stated in part "Upon discontinuation of a controlled drug or after patient death, the hospice registered Nurse (RN) acting within the scope of employment within the place of residence of a hospice patient, can assist with destruction of the controlled substance(s) in the home. The RN will document and record in the clinical record: a. The drug name, strength and quantity destroyed. Documentation: e. Documentation of the disposal by hospice personnel will be documented and filed in the Clinical Record. " Record # 61414: Review of death visit note dated 2/19/22 revealed that documentation lacked evidence of controlled substances Tramadol and Promethazine destruction as per agency policy. The Director of Nursing stated in interview during a joint review of the clinical record failed to include documentation of the destruction of controlled substances as per agency policy.