Every finding on record at Renaissance Hospice and Palliative Care, LLC

Observed in Record Review. In 7 of 7 patient records reviewed, it was noted that the organization did not ensure that the Hospice Election and Consent Forms were completed as required. For example, a review of the Hospice Election Form [HosInpt#1, HosInpt#2, HosInpt#3, RRHV#1, RRHV#2, RRHV#3, and RRHV#4] revealed no documented evidence that at the time of admission a discussion related to the Hospice Election Statement Addendum and whether or not it was requested was completed. This observation was reviewed with agency leadership.

Observed in Record Review. In 1 of 17 patient records reviewed, it was noted that the organization did not ensure that patient specific comprehensive assessments included all required information. For example, during a review of the medical record for RRNHV#8, the clinician documented the following information: Wound care to site as follows: using aseptic technique, cleanse site with wound cleanser, pat dry, apply gentamicin ointment, cover with gauze BID”. A subsequent review of the plan of care orders revealed the location of the wound was the right side of the patient’s neck. During a review of the initial comprehensive assessment, it was noted that a description of the patient’s wound at the right side of the neck was not documented. This observation was reviewed with agency leadership.

Observed in Record Review. In 1 of 17 patient records reviewed, it was noted that the organization did not ensure updated comprehensive assessments included progress towards desired outcomes. For example, a review of RRNHV#3, revealed that since a goal statement related to falls prevention was not established; the requirement to ensure the updated comprehensive assessment included the patient's progress toward goals and outcomes related to falls prevention was not documented. This observation was reviewed with agency leadership.

Observed in Record Review. In 4 of 17 patient records, it was noted that the organization did not ensure goals were individualized to the patient’s needs and condition. During a review of the medical record for HosInpt#2, the following goal statements were noted: “Patient free of any signs/symptoms of infection” and “Complete healing of wound without complication”. The goal statement(s) did not include a method to measure the effectiveness of problem interventions. The stated timeframe of six weeks was not a realistic measurement to assess the implementation of problem interventions related to infection and wound care. Example #2: During a review of the medical record for HosInpt#3, the following information was noted: The comprehensive assessment documented that the patient’s level of consciousness was unresponsive. The FLACC scale was used for pain assessment. The goal for the pain problem was: “Patient will be free or verbalize an acceptable pain level with current pain management regimen”. This goal statement was not specific to the patient’s needs and did not include a method to measure “acceptable pain level”. In addition, the plan of care included the following goal statement: “Maintenance of respiratory baselines as evidenced by breathing at optimal level within disease parameters”. This goal statement did not include a method to measure “breathing at optimal level”. Example #3: During a review of the medical record for RRHV#2, the following goal statement was noted: “Anxiety/agitation controlled through course of care”. This goal statement did not include a method to measure “controlled”. In addition, the timeframe of “through course of care” is not a realistic time frame to address symptoms of anxiety and agitation. Example #4: A review of the medical record for RRNHV#3, revealed that during the 2nd week of services the patient experienced a fall. The plan of care was not updated with a goal statement to evaluate interventions related to fall prevention. This observation was reviewed with agency leadership.

Observed in Record Review. In 3 of 17 patient's records, it was noted that the plan of care did not include interventions based on the problems identified in the comprehensive assessment. For example, during a review of the plan of care for RRHV#1, the following goal statement(s) were noted: Patient/Caregiver can describe measures to reduce/prevent fatigue and Family/Caregiver will demonstrate the ability to cope with limitations. The plan of care did not include interventions to educate the patient and caregiver on measures to reduce/prevent fatigue; and the plan of care did not include interventions to educate the patient and caregiver on measures to address coping limitations. Example #2: A review of the medical record for RRHV#2, revealed that the patient had a goal statement titled “Anxiety/agitation controlled through course of care”. The plan of care did not include interventions to manage symptoms related to anxiety/agitation; the plan of care did not include interventions to provide education for the patient’s caregiver related to the care and coping strategies of anxiety/agitation symptoms. In addition, the plan of care had a goal statement related to bowel elimination problems. The Plan of Care did not include interventions related to the management of bowel incontinence; and the plan of care did not include interventions related to providing education to the patient’s caregiver for the care of the patient’s skin related to bowel incontinence. Example #3: A review of the medical record for RRNHV#3, revealed that the patient had a plan of care problem titled Impaired Skin Integrity. The plan of care did not include interventions for the management and treatment of a stage 2 ulcer at 2nd toe of left foot. The plan of care did not include interventions to provide education related to the wound care, and strategies to protect the patient’s skin integrity. In addition, the patient experienced a fall during the 2nd week of services. The plan of care was not updated with interventions to maintain patient safety, and strategies to prevent injury. This observation was reviewed with agency leadership.

Observed in Tracer Activities. During the Volunteer Program review the organization did not document effective recruitment for volunteers used in direct patient care services. Recruitment efforts resulted in two (2) administrative volunteers for 2024. Efforts to recruit volunteers for direct patient care roles was not documented. This observation was reviewed with agency leadership.

Observed in Competency Session. During the Volunteer employee competence session, it was noted that the organization did not have written policies and procedures describing its methods to perform assessment of volunteer employee competence. This observation was reviewed with agency leadership.

Observed in Record Review. In 2 of 2 discharge records reviewed, it was noted that a discharge/transfer summary that included all required information was not completed. For example, a review of the medical records for RRDC#1, and RRDC#2, revealed no evidence that a discharge summary including the following information was documented: 1) A summary of the patient’s stay, including treatments, symptoms, and pain management, 2) The patient’s current plan of care, and 3) The patient’s latest physician orders. This observation was reviewed with agency leadership.

Observed in Individual Tracer. In 4 of 4 Individual Tracers, the organization did not ensure that a copy of its written policies and procedures on the management of controlled medications was provided to the patient or the patient’s representative and family. For example, during survey activities for RRHV#1, RRHV#2, RRHV#3, and RRHV#4, it was noted that a copy of the organizations written policies and procedures related to the management of controlled medications was not present in the patient and family handbook. An additional review of the medical records for the identified patient's revealed no documented evidence that staff documented that this policy was provided and discussed. This observation was reviewed with agency leadership.

Observed in Record Review. In 1 of 17 patient records reviewed, it was noted that the organization did not ensure that an evaluation of patient education and training was provided when required. For example, during a review of the medical record for RRNHV#3, it was noted that during the 2nd skilled nurse visit, a clinician documented the following information: “Patient’s daughter [name omitted] performed wound care as ordered prior to SN visit”. However, there was no documented evidence that an evaluation of the patient’s caregiver competence to perform the wound care treatment was performed. This observation was reviewed with agency leadership. Observed in Record Review. In 1 of 17 patient records reviewed, it was noted that the organization did not ensure patient education and training was provided based on the patient’s assessed needs. For example, during a review of the medical record for RRNHV#3, it was noted that during the 2nd skilled nurse visit, a clinician documented the following information: “Patient’s daughter [name omitted] performed wound care as ordered prior to SN visit”. However, there was no documented evidence that the patient’s caregiver received education and training related to wound care treatment. This observation was reviewed with agency leadership.

Observed in Building Tour. It was observed that the lobby sliding doors which were the marked egress path had thumb latches on the doors which required two steps to open the doors in an emergency. This was verified by the Facility Manager. The surveyor discussed the Life Safety deficiency with the organization, and it was determined that the following ILSMs will be implemented until the deficiency has been resolved and according to the organization's ILSM policy: Observed in Building Tour. It was observed in the fire alarm panel room that there was a magnetic lock on the door. The push to exit had to be used to exit the room because there was no proximity sensor to release the door in the path of egress. This was verified by the Facility Manager. The surveyor discussed the Life Safety deficiency with the organization, and it was determined that the following ILSMs will be implemented until the deficiency has been resolved and according to the organization's ILSM policy: Observed in Building Tour. It was observed that there was a ceiling wire to the suspended ceiling wrapped around the fire sprinkler piping. This was verified by the Facility Manager. The surveyor discussed the Life Safety deficiency with the organization, and it was determined that the following ILSMs will be implemented until the deficiency has been resolved and according to the organization's ILSM policy:

Observed in Document Review. It was observed that the Fire Department Connection(FDC) inspection documentation did not include the NFPA standard(s) referenced for the activity. This was verified by the Facility Manager.

Observed in Record Review. In 4 of 7 active patient records reviewed on service greater than five days, During HV# 1 HV# 2, RR# 3, and RR# 9's patient records review it was noted the organization had not ensured the plan of care was based on the patient's goals and time frames, and services required to meet those goals. For example: review HV# 1’s patient record revealed a stage 1 pressure ulcer with interventions for pressure ulcer to include A&D ointment and low air loss mattress. Review of HV# 1’s plan of care and subsequent updates to the plan of care/Interdisciplinary Team (IDT) revealed no documented goal related to the pressure ulcer. During HV# 2’s home observation the patient was observed with an indwelling foley catheter. Review of HV# 2’s plan of care and subsequent updates to the plan of care/IDT revealed no documented goal related to the catheter. Review of RR# 3’s start of care registered nurse (RN) comprehensive assessment revealed documentation that RR# 3 was experiencing “moderate pain” using the Wong-Baker pain assessment. Review of the plan of care and subsequent updates to the plan of care/IDT revealed no documented pain goal. Review of RR# 9’s patient record revealed RR# 9’s terminal diagnosis was chronic obstructive pulmonary disease (COPD). Review of RR# 9’s start of care RN comprehensive assessment revealed RR# 9 had Stage 2 pressure ulcer and was receiving oxygen at 2-3lpm per nasal cannula. Review of RR# 9’s plan of care and subsequent updates to the plan of care/DT revealed no documented wound goal or respiratory goal. This was reviewed, discussed, and validated with the Administrator/Director of Patient Care Services.

Observed in Record Review. In 4 of 7 active patient records reviewed on service greater than five days, During HV# 2 and RR# 9's patient records review it was noted the organization had not ensured the plan of care included all the services needed for palliation and management of the terminal illness and related conditions. For example: review of HV# 2's start of care registered nurse comprehensive assessment revealed HV# 2 had an indwelling Foley catheter. Review of the initial plan of care revealed the intervention for a Foley catheter as needed for urinary retention. Further review of the initial plan of care and subsequent updates to the plan of care/Interdisciplinary Team (IDT) revealed no interventions related to the indwelling Foley catheter, such as the size or when it needed to be changed. Review of RR# 9’s patient record revealed a terminal diagnosis of chronic obstructive pulmonary disease (COPD). Review of the start of care RN comprehensive assessment revealed RR# 9 was receiving oxygen at 2-3Lpm per nasal cannula. Review of the plan of care and subsequent updates to the plan of care/IDT revealed the intervention to assess the patient's use of oxygen and oxygen effectiveness with no further documentation regarding the dose and route of the oxygen. This was reviewed, discussed, and validated by the Administrator/Director of Patient Care Services

Observed in Record Review. During HV# 1, HV# 2, and RR# 1's patient records review it was noted the organization had not ensured the plans of care included measurable outcomes anticipated from implementing and coordinating the plan of care. For example: review of RR# 1’s plan of care revealed a goal: insufficient knowledge of disease process/treatment/potential complications with no indication what disease process, which treatment and potential complications. HV# 1’s plan of care revealed a shortness of breath goal of dyspnea not worsening with no indication on how to measure indication of worsening dyspnea. Review of HV# 2’s plan of care revealed a Pain goal: pain episode will be controlled with current pain regimen with no indication on how to measure when pain was controlled. This was reviewed, discussed, and validated with the Administrator/Director of Patient Care Services.

Observed in Patient Home. In 1 of 3 home visits conducted, During HV# 1's home observation, it was noted the organization had not ensured the patient record contained information that reflected the patient's care, treatment, or services. For example: HV# 1 was observed receiving oxygen at 12 lpm per nasal cannula. Review of the plan of care/medication list and all subsequent updates to the plan of care/Interdisciplinary Team (IDT) revealed oxygen at 15 lpm per nasal cannula. Review of the nursing visit documentation revealed the patient was receiving oxygen at 12 lpm per nasal cannula for approximately 30 days prior to the surveyor review of the patient's record. This was reviewed, discussed, and validated by the Administrator/Director of Patient Care Services.