Every finding on record at Rosedove, Inc.

Observed in Emergency Management Session. The organization failed to conduct a hazard vulnerability analysis utilizing an all-hazards approach as evidenced by the hazard vulnerability analysis did not include emerging infectious diseases, this was observed and validated by the Administrator and DON

Observed in Emergency Management Session. The organization failed to review and makes necessary updates based on after-action reports or opportunities for improvement to the following items every two years as evidenced by not completing an after action report following community and table top drill, this was observed and validated by the Administrator and DON

Observed in Emergency Management Session. The organization does not have a written plan for managing interruptions to its information processes (paper-based, electronic, or a mix of paper-based and electronic) as evidenced by the EMR system has been down for 2 days, they cannot access any patient information and are relying on information that is in patients home folder, this was validated by the DON and Administrator Observed in Emergency Management Session. The organization failed to have a written plan for scheduled and unscheduled interruptions of electronic information systems and IT or training for staff on alternative procedures as evidenced that the EMR has been down for 3 days, this was observed and validated by the Administrator and DON

Observed in Record Review. In 10 of 10 patient records reviewed, The organization failed to document in writing the need for volunteer services to offer support or respite to the patient, family, or other caregivers during the comprehensive assessment in RRHV#1, RRHV#2, RRHV#3, RRNHV#1, RRNHV#2, RRNHV#3, RRNHV#4, RRNHV#5, RRNHV#6 and RRNHV#7, this was observed and validated by the Administrator and DON

Observed in Record Review. In 1 of 10 patient records reviewed, The organization failed to assess the patient and the patient's condition according to defined time frames as evidenced in RRNHV#7: Spiritual support not completed within 5 days and no documentation as to why, this was validated by the LVN and DON

Observed in Record Review. In 1 of 10 patient records reviewed, The organization failed when using external resources to meet the patient’s needs, coordinates the patient’s care, treatment or services in accordance with orders or prescriptions as evidenced in RRNHV#5:Wound Care Experts PA sees patient weekly for wound care, this information is not on the POC, this was validated by the LVN and DON

Observed in Data Session. The organization failed to establish priorities for performance improvement as evidenced by the QAPI program, failed to address DME, pharmacy, bereavement, contracted or volunteer services, this was observed and validated by the Administrator and DON

Observed in Record Review. In 2 of 2 patient records reviewed, The hospice failed to develop a bereavement plan of care that specifies the type of bereavement services to be offered and the frequency of service delivery as evidenced in RRBR#1 and RRBR#2, the bereavement risk assessment indicated that the bereaved was at a high risk and moderate risk respectively, yet the only interventions planned were to send a standard series of mailings with no indication of other proposed interventions, this was observed and validated by the Administrator and DON

Observed in Record Review. In 2 of 10 patient records reviewed, A registered nurse who is a member of the interdisciplinary group and is responsible for hospice aide supervision failed to add all required written patient care instructions for the hospice aide as evidenced in RRHV#1 and RRNHV#5 : HHA assignment did not specify precautions related to wound care, this was observed and validated by the Patient Care Coordinator and DON

Observed in Individual Tracer. In 1 of 9 HR files reviewed, The organization failed to provide hospice orientation to contracted including relevant policies and procedures as evidenced in HR#9: contracted physical therapist did not receive orientation on hospice philosophy or policies, this was validated by the DON

Observed in HR File Review. In 1 of 8 HR files reviewed, The organization failed to define the competencies of volunteers who provide patient care, treatment, or services as evidenced in HR#7, their was no competency completed for the volunteer, this was validated by the DON

Observed in Record Review. In 1 of 2 patient records reviewed, The author was not identified in the patient record as evidenced in RRDC#1:revocation paperwork signed by spouse but not by hospice staff, this was observed and validated by LVN and DON Observed in Record Review. In 7 of 10 patient records reviewed, The organization failed to authenticate entries in the patient record as evidenced in RRHV#1: IDG notes not signed by whole team for 63 days, RRHV#2, RRNHV#1, RRNHV#2, RRNHV#3, RRNHV#4 IDG notes not signed for 49 days. In RRHV#3 IDG note not signed for 91 days, this was observed and validated by the Administrator and DON

Observed in Patient Home. In 3 of 3 home visits conducted, The organization failed to provide the patient’s most recent hospice plan of care at the board and care facility as evidenced in RRHV#1: the last POC was dated 4 weeks ago and previous one was 13 weeks. In RRHV#2: last POC was 4 weeks ago and previous one was 6 weeks, and RRHV#3: the last POC updated in home folder was 4 weeks ago, this was observed by the LVN and validated by the DON

Observed in Emergency Management Session. The Hospice Organization did not evaluate the disaster plan in the last two years. During review of the organizations plan it was noted hat there was no documentation of the plan being updated in the last two years. This was validated with the leadership during the Emergency Management Session.

Observed in Emergency Management Session. Upon review of the organization’s emergency management plan and training, there was no documentation to validate staff were provided emergency management training at least every 2 years. This was validated in discussion with the Director of Nursing.

Observed in Emergency Management Session. The Hospice Organization did not evaluate and test the effectiveness of the emergency plan. During review of the organizations Emergency Management plan it was noted there was no documented evaluation of the drill and tabletop exercises that had been performed over the past 3 years. This was validated with the leadership team during the Emergency Management Session.

Observed in Record Review. On 1 of 5 patient records where the patient was discharged from care, documentation was not completed to support that the patient revoked their hospice benefit. On review of HSRR#8, the patient went to the hospital and the daughter called to notify the agency of the hospitalization, however, there is no signed statement that the patient or patient representative revoked hospice. This finding was reviewed with the Director of Nursing.

Observed in Patient Home. In 1 of 3 Hospice Home visits the nurse did not follow disinfectant manufacture instructions for use to reduce the risk of infections associated with supplies/equipment. During HSV/RR#1 the Nurse used Lysol wipes to clean vital sign equipment in the patient home after use and did not follow the contact time as specified by the manufacturer of 4 minutes. This was reviewed and validated with the Director of Nursing.

Observed in Record Review. In 4 of 10 patient record reviewed with aide services, the organization did not conduct a Hospice aide supervision every 14 days. Upon review of HSV/RR#2, it was noted that two supervisory visits were completed both two days late. Upon review of HSRR#7, it was noted that two supervisory visits were completed late, one 14 days late and one 2 days late. On review of HSRR#8, it was noted that two aide supervisory visits were completed late, one was two days late and the other was 15 days late. On review of HSRR#9, it was noted that there was one instance of missed aide supervision that was 2 days late. This finding was reviewed and validated with the Director of Nursing.