Every finding on record at Safe Haven Hospice, LLC

Observed in Record Review. In 3 of 13 patient records reviewed, the organization did not assess the patient according to defined time frames. In RR#6, RR#8, and RR#10, it was noted the Chaplain had not completed the initial comprehensive assessment within five days of the election of hospice care. This was reviewed with the Director and Clinical Manager.

Observed in Record Review. In 4 of 14 patient records reviewed for bereavement, the organization did not assess/reassess its patients by including anticipated discharge needs related to bereavement needs and survivor risk factors before and after the death. In RR#6, there was no initial bereavement assessment completed/documented at the time of the patient's admission to hospice. In BR#1, BR#2, and BR#3, the post-death bereavement assessment was not completed/documented. This reviewed with the Director and Clinical Manager.

Observed in Patient Home. In 5 of 13 patient records reviewed, the organization did not plan the patient's care by including all drugs, and treatments needed for the palliation and management of the terminal illness and related conditions. In record review for HV#1 and RR#2, the patient's medication profile noted the patient was on multiple prn medications for constipation with no clear indications for use (which prn medication to take when). In RR#3, it was noted the patient had two skin cancer lesion wounds, with the stated goals related to wound care. There was, however, no specific wound care treatment orders included/documented in the hospice plan of care. In RR#5 and RR#8, it was documented the patient had an indwelling Foley catheter, but there was no treatment orders included in the plan of care related to the urinary catheter care/changes/size. This was reviewed and verified with the Clinical Manager.

Observed in Record Review. In 12 of 13 patient records reviewed, the organization did not plan the patient's care. The hospice interdisciplinary group did not review, revise, and document updates to the plan of care at least every 15 days. In HV#1, HV#2, HV#3, RR#1, RR#2, RR#3, RR#4, RR#5, RR#6, RR#7, RR#8, and RR#10, it was noted the interdisciplinary team (IDT) met every 14 days, however there was no documentation on the IDT plan of care review/update note related to the MSW or the Chaplain. The Clinical Manager confirmed that the MSW and Chaplain attend the IDT Meetings, and participate in the review process, however only RN updates/revisions were documented in the hospice plan of care. This was reviewed with the Director and Clinical Manager.

Observed in Infection Control System Tracer. The organization did not set goals to minimize the possibility of spreading infections based on the identified risks. During the Infection Control System Tracer discussion, it was noted there were no written infection prevention and control goals addressing prioritized risks. This was discussed and verified with the Director and Clinical Manager.

Observed in Record Review. In 3 of 3 bereavement records reviewed, the organization did not plan the patient's care by developing a bereavement plan of care. In BR#1, BR#2, and BR#3, a bereavement plan of care that specified the type and frequency of bereavement services to be provided was not developed/documented. It was confirmed by the Bereavement Coordinator that entry of the bereavement plans of care into the hospice record was late, but that bereavement services were being provided. This was reviewed with the Director.

Observed in Patient Home. In 1 of 1 hospice aide visits, the organization did not provide hospice aide services as ordered in the plan of care consistent with the aide's training. In HV#2, the plan of care indicated a bed bath was to provided every visit. Upon completion of the bath, it was noted the hospice aide had not cleaned/washed the patient's face as outlined in the organization's Giving a Bed Bath procedure. This was reviewed/confirmed by the Clinical Manager.

Observed in HR File Review. In 3 of 7 HR files reviewed, staff competence was not initially assessed and documented as part of orientation. In HR#1, HR#3, and HR#6, staff initial competency was not assessed and documented. This was reviewed with the Director.

Observed in Record Review. In 1 of 13 patient records reviewed, the record did not contain information that reflected the patient's care, treatment, or services. In RR#10, the hospice record did not include specific information/documentation related to the disposal of controlled medications in the home at the time of the patient's death. The patient's plan of care did include liquid Morphine-Sulfate, Hydrocodone-Acetaminophen, Tramadol, and Lorazepam. The section on the death at home note related to medication disposal was blank and not documented by the RN according to the organization's policy and procedure for disposal of controlled medications. This was reviewed and verified with the Clinical Manager.

Observed in Patient Home. In 1 of 13 patient records reviewed, the record did not contain information that reflected the patient's care, treatment, or services. In review of the record for HV#1, it was noted the patient's medication profile/list in the hospice plan of care did not include the accurate frequency for Bisacodyl suppository. The medication list indicated the patient was receiving the suppository daily, but it was confirmed by the facility staff that the Bisacodyl suppository was prn. This was reviewed with the Clinical Manager.